Putrino Lab Profile picture
May 1, 2022 25 tweets 10 min read Read on X
Ok. As promised, here is a super-🧵 on cognition and #LongCovid. This will be a combination of published material and things that we have observed in-clinic. This is not intended to be definitive nor epidemiological and so it is highly likely that your personal experience (1/n)
may deviate significantly. This is about my reading and experience of cognition and #LongCovid but from what I have seen shared in the comments of my tweet yesterday, it seems that much of this may apply to other infection-associated chronic illnesses (h/t @microbeminded2) (2/n)
such as #MECFS, #Lyme and #dysautonomia/#POTS to name a few. Let’s start out with naming. I try not to use the term “brain fog” because I don’t think it conveys the seriousness. People with LC are experiencing cognitive dysfunction that often results in cognitive impairment (3/n)
So what sorts of cognitive dysfunction are people experiencing? Most often, we observe issues with high-level cognitive functions: executive function (the ability to process and synthesize information, form plans, emotionally regulate), speech production (esp. word finding) (4/n)
less often, we are seeing issues with short and long-term memory. Now, let me qualify this because I know so many people feel like their short-term memory is shot: if I test your short-term memory exclusively, I.e. I say “remember these five words”, *most* folks with LC can (5/n)
recall the five words I give them. However, in their day-to-day they have short-term memory fails them because they have issues with executive function: issues with selecting which things are *important* to attend to and remember, and therefore they don’t remember. In cases (6/n)
of hospitalized COVID and #PICS we are seeing more pure memory issues presenting, which is another example of how PICS is a different kettle of fish to #LongCovid and shouldn’t be conflated. So. Executive function and language issues are the big areas of cog dysfunction (7/n)
we are seeing with LC. What sort of cognitive impairment does this result in? The majority of ppl we see have “mild” cognitive impairment (a misnomer because anything that messes with your sense of identity should never be called “mild”), but in this context it means that (8/n)
they can still function, but everything takes more cognitive effort. I.e. can still drive, but you need a minute to recover. Can still be on an intense, challenging work zoom, but need to dim the lights and chill for 20 mins afterwards. The general ability to “function” but (9/n)
not thrive in the way that they used to which is not only incredibly distressing but also incredibly maddening when it is met with “you know, everyone forgets things” or, “this is just normal aging” from a health care provider. #LongCovid cog impairment is real and NOT (10/n)
just some by-product of social isolation, depression or natural aging. That is a lazy clinical association that is indicative of how little we understand how to diagnose and treat these things. In addition to folks with mild cog impairment, many ppl with LC experience (11/n)
mod-severe impairment. These are the people who can no longer safely drive, no longer work the hours or the job that they used to and in many cases require assistance with activities of daily living. Sadly, just so you know where the line is, with our current evaluations (12/n)
of cognitive disability sometimes even this level of cognitive impairment does not trigger the need for intervention b/c you can still “function” I.e. you don’t need a home health aide at your house every day to assist you. This is extremely frustrating and needs to change (13/n)
because so many with #LongCovid, #MECFS, #POTS, #Lyme and many others (don’t even get me started on acquired brain injury) get no care because they’re “high functioning enough” to “get by” according to payors, worker’s comp and long-term disability. This is criminal. (14/n)
Also of note is that much of this cognitive impairment can be intermittent (it comes and goes), meaning that you can see your doctor and feel fine (due to time of day of the appointment or the fact that your nervous system is primed for your appointment) but be highly (15/n)
symptomatic as soon as you leave or the day or week after. That’s why #medtwitter I implore you, don’t stop at “well you look fine to me”, or “all your tests are within normal limits” to your #LongCovid patients. LISTEN to them, UNDERSTAND that cog impairment is often (16/n)
intermittent (not just in LC but many conditions) AND that most cognitive screenings (like the MOCA) have significant ceiling effects, meaning that someone can pass the MOCA with flying colors and still have serious cognitive dysfunction. And impairments. So, we have a (17/n)
situations where somewhere in the neighborhood of 60-90% (depending on the study) of ppl with #LongCovid are reporting some form of cognitive dysfunction. The next question is “why”? We are still searching for answers, but let me give you my best theories based on the lit. (18/n)
Our brains account for about 20% of our overall energy requirements, which is staggering given that it accounts for 2% of our total body mass. The brain is an energy hog, and the more publications that emerge (in both #LongCovid and #mecfs) we see that these are so often (19/n)
conditions where our physiology is in energy crisis: chronically low waking cortisol, mitochondrial dysfunction, issues with getting blood where it needs to go due to platelet pathology and microclots (h/t @resiapretorius, @dbkell, @doctorasadkhan and #teamclots) and (20/n)
neuroinflammation and autoantibody production (h/t @VirusesImmunity and @michelle_monje) all leads to a perfect storm of cognitive dysfunction that is serious, but often intermittent, affects highest functioning parts of our brain first - executive function requires a LOT (21/n)
of energy - and can be MASSIVELY affected by our environment and daily demands (body position, environmental temperature, level of exertion (emotional, cognitive, physical), diet, hydration, sleep, etc). Ok. So what do we do? Test, test, test everyone’s cognition, and test (22/n)
regularly. I know, I know all my cog neuroscience friends - we don’t have baselines. Guess what - DOESN’T MATTER. Test everyone regularly to get a sense of their personalized cognitive performance “fingerprint” and work WITH them to optimize. My team does this EVERY DAY (23/n)
with high cognitive performers like eSports athletes and F1 drivers and it works to improve performance. So this is where we start. Use cognitive tests without ceiling effects that will show you where your patient lands in a normative population. We personally use (24/n)
@BrainCheck, but there are many that do a good job. Cognitive remediation therapies and cog rehab will help so long as they aren’t too exerting, but they must not replace the need for clin research that addresses physiology. I’m out of tweets on this thread, hope this helped! 🙏🏻

• • •

Missing some Tweet in this thread? You can try to force a refresh
 

Keep Current with Putrino Lab

Putrino Lab Profile picture

Stay in touch and get notified when new unrolls are available from this author!

Read all threads

This Thread may be Removed Anytime!

PDF

Twitter may remove this content at anytime! Save it as PDF for later use!

Try unrolling a thread yourself!

how to unroll video
  1. Follow @ThreadReaderApp to mention us!

  2. From a Twitter thread mention us with a keyword "unroll"
@threadreaderapp unroll

Practice here first or read more on our help page!

More from @PutrinoLab

Jun 27
In honor of #PrideMonth2025, I just wanted to take a moment to discuss the crucial role of intersectionality, gender and inclusion in research, specifically as it relates to our research involving #LongCOVID, #MECFS, chronic #lyme and other complex chronic illnesses. As we 1/
work to understand these illnesses, we must often contend with the fact that they are characterized by a diverse array of symptoms that cause dynamic disability (fluctuating severity of symptoms that can lead to fluctuating levels of disability). As we've learned, so many 2/
different things can cause symptom changes: exertion, temperature fluctuations, dietary and hydration changes, chemical, mold and pathogen exposures and many other variables. Attempting to track all the variables that can influence someone's day-to-day health when they live 3/
Read 17 tweets
Jun 17
As with most of the harmful #LongCOVID rhetoric that gets occasionally flung in my direction, I was going to ignore this particularly egregious take, but a few members of the community who I respect asked me to respond and this account also chose to sling mud at someone that 1/
I truly admire, @VirusesImmunity, and I just cannot let that stand. Let's start with the obvious: we are not "heroes", we are not "saviors". We are people. People who saw a disaster occurring and did our best to lend a hand. I am fallible, I am frequently wrong and if you 2/
follow me or have seen my tweets you know that I am open to constructive feedback and honest, good-faith communication. I have 5 years of receipts on that in this community and 2 decades of receipts in other communities. Now, let's get specific about the roadmap document. In
3/
Read 19 tweets
Jun 14
Since I posted two threads about PEM yesterday, some general feedback themes have been coming up, so I just wanted to address them:
1) Thank you to those who rightly pointed out that in my description of PEM I should have mentioned that PEM can have permanent consequences to
1/
someone's baseline. Not dissimilar to what we see in multiple sclerosis, some people can bounce back from their PEM without a noticeable effect to their baseline, whilst others appear to experience progressive loss of function with every bout of PEM (or a combo of the two).
2/
Since we can disambiguate who is who, it is CRUCIAL that clinical providers educate PEM on pacing to help folks manage their daily energy budget without pushing into PEM.
2) A few people took exception to me calling pacing the "magic word". That's fair. I didn't mean to imply
3/
Read 6 tweets
Jun 13
Ok, so after that (unintentional) cliffhanger, let's talk about energy production infrastructure and post-exertional malaise (PEM) in people with infection- and exposure-associated chronic illnesses (IACIs) such as #LongCOVID, #MECFS, chronic #Lyme and more. Let's start with 1/
how cells produce energy. ATP is the body's energy currency, and we only know how to make this currency from glucose, so our bodies need to turn glucose into ATP. They can do so either aerobically (using oxygen and mitochondria) or anerobically (fast, but inefficient, no 2/
mitochondria). Energy is never free in this universe, so both processes produce both ATP and waste
- Aerobic: 36-38 ATP units per glucose unit, producing reactive oxygen species (ROSs) as waste
- Anerobic: 2 ATP units per glucose unit, producing pyruvate and lactate as waste
3/
Read 25 tweets
Jun 13
Wanted to put forward a thread about #PEM since there have been some new developments and also because I just need to get some of this out of my head and work through it. Folks with infection- and exposure-associated chronic illnesses (IACIs) like #LongCOVID, #MECFS, 1/
chronic #lyme and other tick- and vector-borne illnesses will often experience post-exertional malaise (PEM). In fact, it is often thought of as a cardinal hallmark of many of these diagnoses. To start, a simple working definition of PEM: it is a condition that emerges when 2/
somebody physically, mentally or emotionally exerts themselves beyond a certain point, causing a delayed worsening of symptoms that can last days, weeks or even months. NB: There is much more to PEM than this definition, and one of my favorite explainers is @LongCOVIDPhysio's 3/
Read 25 tweets
May 17
A few comments that might be helpful after a phenomenal couple of weeks learning from brilliant people in #MECFS, #LongCOVID, chronic #Lyme and infection-associated chronic illness (IACI) communities and still buzzing after yesterday's @polybioRF meeting. These illnesses are 1/
complex and are going to require equally complex science to solve. When it comes to studying and managing these illnesses, I rarely feel sure about anything, but if I'm sure of one thing it is this: anyone telling you that one drug/one approach will solve all cases of an IACI 2/
is probably selling that one drug/one approach. These illnesses are complex: Biomarker-driven, personalized dispensation of combination therapies are going to be crucial to addressing the problem. Let's talk through an example (an example that assumes a perfect world where we 3/
Read 16 tweets

Did Thread Reader help you today?

Support us! We are indie developers!


This site is made by just two indie developers on a laptop doing marketing, support and development! Read more about the story.

Become a Premium Member ($3/month or $30/year) and get exclusive features!

Become Premium

Don't want to be a Premium member but still want to support us?

Make a small donation by buying us coffee ($5) or help with server cost ($10)

Donate via Paypal

Or Donate anonymously using crypto!

Ethereum

0xfe58350B80634f60Fa6Dc149a72b4DFbc17D341E copy

Bitcoin

3ATGMxNzCUFzxpMCHL5sWSt4DVtS8UqXpi copy

Thank you for your support!

Follow Us!

:(