This article was published on June 10, 2022
Question from a Member:
What do you give to patients with POTS who complain of ADHD-type of symptoms?
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For an overview of postural tachycardia syndrome (POTS), also sometimes called postural orthostatic tachycardia syndrome, please see the following article on this website:
In that article, we noted that:
– Postural tachycardia syndrome (POTS) is a clinical condition in which on standing up the person has an excessive increase in heart rate along with multiple symptoms, both of which are relieved on lying down.
– POTS is a common and serious disorder. About 25% of these patients are disabled (Raj et al., 2018).
– Mental health clinicians need to know about POTS because it is commonly misdiagnosed as an anxiety disorder.
– Also, as we will discuss here, these patients commonly have clinically significant cognitive impairments.
Cognitive complaints in POTS are common and very bothersome
Yes, patients with POTS often complain of cognitive impairments including, in no particular order (Miller et al., 2020; Raj et al., 2018):
– “Brain fog” (“cloudy”)
– “Mental fatigue”
– Inattention (“difficulty focusing”)
– Impaired memory (“forgetful”)
– Decreased cognitive processing speed (“slow”, “difficulty thinking”)
– Decreased concentration
– Executive dysfunction
– Difficulty finding the right words
Are these symptoms clinically important?
Yes, they are—because they are very bothersome to these patients (Raj, 2013).
Will it be helpful to ask if the cognitive problems occur ONLY on standing up?
No, that is not the best question. Instead, we should ask whether, like other symptoms found in POTS, the cognitive problems are typically worse when patients with POTS stand up (Miller et al., 2020; Anderson et al., 2014).
But they don’t occur ONLY when the patient stands up. Significant cognitive problems and brain fog are ALSO reported while the patient is sitting or lying down (Raj et al., 2018; Arnold et al., 2015).
Should we order neuropsychological testing?
Studies using formal neuropsychological testing have confirmed the presence of cognitive deficits in these patients (Raj et al., 2018). But when neuropsychological testing is done, the specific deficits that are found vary from study to study, probably because the studies are done in very different ways (Raj et al., 2018).
In routine clinical practice, ordering neuropsychological testing is NOT required or recommended.
Management of cognitive impairments in POTS
We don’t have clear guidance about how to manage the cognitive symptoms associated with POTS. But, here is what we do know.
1. The general management of POTS is likely to also help with the cognitive symptoms
The various interventions used in POTS are not discussed here but those measures are likely to help the cognitive symptoms as well.
As one example, a small study found that rapidly drinking 500 mL of mineral water was associated with improvement in both orthostatic tachycardia and subjective cognitive complaints (Rodriguez et al., 2019).
2. Modafinil can improve alertness in some patients with POTS; several experts have suggested this (for example, Sheldon et al., 2015; Raj, 2013).
A concern with using modafinil is that it may worsen the orthostatic tachycardia (Raj, 2013), so we have to watch out for this. But, in one randomized, placebo-controlled clinical trial, modafinil 100 mg increased sitting and standing blood pressure but did NOT worsen standing heart rate or orthostatic symptoms (Kpaeyeh et al., 2014).
Still, the cautious thing to do, if modafinil is used, is to start with a low dose and slowly go up on the dose while carefully monitoring for possible benefits and/ or side effects. After all, it is not an emergency to treat the cognitive complaints immediately and a delay of a few days should not matter.
3. Methylphenidate. In a small retrospective chart review, about 60% of patients who were started on methylphenidate 10 mg three times a day reported marked improvement at the end of 6 months.
Atomoxetine. Let’s not prescribe atomoxetine to treat the cognitive symptoms of POTS. In a small, randomized, crossover clinical trial, treatment with atomoxetine was associated with worsening of orthostatic tachycardia and associated symptoms (Green et al., 2013).
Anderson JW, Lambert EA, Sari CI, Dawood T, Esler MD, Vaddadi G, Lambert GW. Cognitive function, health-related quality of life, and symptoms of depression and anxiety sensitivity are impaired in patients with the postural orthostatic tachycardia syndrome (POTS). Front Physiol. 2014 Jun 25;5:230. doi: 10.3389/fphys.2014.00230. PMID: 25009504; PMCID: PMC4070177.
Arnold AC, Haman K, Garland EM, Raj V, Dupont WD, Biaggioni I, Robertson D, Raj SR. Cognitive dysfunction in postural tachycardia syndrome. Clin Sci (Lond). 2015 Jan;128(1):39-45. doi: 10.1042/CS20140251. PMID: 25001527; PMCID: PMC4161607.
Green EA, Raj V, Shibao CA, Biaggioni I, Black BK, Dupont WD, Robertson D, Raj SR. Effects of norepinephrine reuptake inhibition on postural tachycardia syndrome. J Am Heart Assoc. 2013 Sep 3;2(5):e000395. doi: 10.1161/JAHA.113.000395. PMID: 24002370; PMCID: PMC3835251.
Kpaeyeh J Jr, Mar PL, Raj V, Black BK, Arnold AC, Biaggioni I, Shibao CA, Paranjape SY, Dupont WD, Robertson D, Raj SR. Hemodynamic profiles and tolerability of modafinil in the treatment of postural tachycardia syndrome: a randomized, placebo-controlled trial. J Clin Psychopharmacol. 2014 Dec;34(6):738-41. doi: 10.1097/JCP.0000000000000221. PMID: 25222185; PMCID: PMC4239166.
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 Sep;227:102692. doi: 10.1016/j.autneu.2020.102692. Epub 2020 Jun 6. PMID: 32526639; PMCID: PMC7369241.
Raj SR. Postural tachycardia syndrome (POTS). Circulation. 2013 Jun 11;127(23):2336-42. doi: 10.1161/CIRCULATIONAHA.112.144501. PMID: 23753844; PMCID: PMC3756553.
Raj V, Haman KL, Raj SR, Byrne D, Blakely RD, Biaggioni I, Robertson D, Shelton RC. Psychiatric profile and attention deficits in postural tachycardia syndrome. J Neurol Neurosurg Psychiatry. 2009 Mar;80(3):339-44. doi: 10.1136/jnnp.2008.144360. Epub 2008 Oct 31. PMID: 18977825; PMCID: PMC2758320.
Raj V, Opie M, Arnold AC. Cognitive and psychological issues in postural tachycardia syndrome. Auton Neurosci. 2018 Dec;215:46-55. doi: 10.1016/j.autneu.2018.03.004. Epub 2018 Mar 27. PMID: 29628432; PMCID: PMC6160364.
Rodriguez B, Zimmermann R, Gutbrod K, Heinemann D, Z’Graggen WJ. Orthostatic Cognitive Dysfunction in Postural Tachycardia Syndrome After Rapid Water Drinking. Front Neurosci. 2019 Apr 9;13:327. doi: 10.3389/fnins.2019.00327. PMID: 31024242; PMCID: PMC6465605.
Shanks L, Jason LA, Evans M, Brown A. Cognitive impairments associated with CFS and POTS. Front Physiol. 2013 May 16;4:113. doi: 10.3389/fphys.2013.00113. PMID: 23720636; PMCID: PMC3655280.
Sheldon RS, Grubb BP 2nd, Olshansky B, Shen WK, Calkins H, Brignole M, Raj SR, Krahn AD, Morillo CA, Stewart JM, Sutton R, Sandroni P, Friday KJ, Hachul DT, Cohen MI, Lau DH, Mayuga KA, Moak JP, Sandhu RK, Kanjwal K. 2015 heart rhythm society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope. Heart Rhythm. 2015 Jun;12(6):e41-63. doi: 10.1016/j.hrthm.2015.03.029. Epub 2015 May 14. PMID: 25980576; PMCID: PMC5267948.
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