Dementia has many causes, and if we want to optimize our chances of avoiding it, we need to re-consider what we might do to achieve that goal. There is also decreased cognition in persons with MS, and they have been included in trials of exercise and cognition, Graded Exercise Training (GET) Smart trial.

Healthy aging may aid us in our determination to maintain our cognitive (thinking processes) activities, but there remains a verified relationship between decreased cognition and normal aging. Neuroimaging studies of the brain have indicated that changes in brain size occur in mid-adulthood and may start as early as the 20s, with increased advances at about 5% per decade beginning at age 40.

Biochemically, outlined in much of the research, there seems to be a change in the potential for our body’s neurotransmitters to assist in our body’s retaining brain cell functioning, which may be directly related to our body’s exercise practices. In fact our body may benefit from what is known as brain-derived neurotrophic factors (BDNF) as well as neurotransmitters and that can benefit from a regular course of exercise. Why are we interested in BDNF?

Brain-derived neurotrophic factor (BDNF) is one of the…factors that support differentiation , maturation, and survival of neurons in the nervous system and shows a neuroprotective effect under adverse conditions. If we can retain our ability to produce this vital factor, we are ahead of the game when it comes to a variety of negative events affecting our brain’s ability to remain active and to repair itself when needed.

A review of aerobic exercise has indicated that exercise may slow down age-related cognitive decline. Further exploration of 68 studies related to cognitive decline and exercise produced evidence that not only does physical exercise provide added cardiovascular and fitness benefits, it also may have potential to slow the progression of cognitive decline in any persons with mild cognitive impairments.

Increasing numbers of persons will continue to experience cognitive decline not merely by advancing age, but brain injury or disease which can lead to dementia as well as a progressive cognitive global decline in memory and executive functioning due to illness. Might Covid-19 brain fog patients derive benefit from an exercise program? I haven’t seen literature on that yet.

Currently, although over 400 clinical trials have been initiated in the area of cognitive decline, specifically Alzheimer’s disease, the results have not yet proven to be what we would wish. In addition, the yearly cost of pharmaceutical products that promise some improvement or suppression of cognitive decline has been disappointing and hugely expensive with one drug being priced over $100K/yr. The expense would place these medication’s beyond the reach of the millions worldwide who will require them in the coming decades.

In light of these disappointing research explorations, we must begin to consider low cost, side-effect free methods that, when applied on a regular basis, may either delay or slow cognitive decline. The current non-pharmaceutical interventions include cognitive and behavioral training, diet, socialization, music therapy and physical exercise.

The literature has found that not only is physical exercise (PA) exercise beneficial in early life, it has obvious advantages later in life.

PA in early- and mid-adulthood independently predicted higher initial memory level and slower memory decline in later life, respectively. Early-adulthood PA was indirectly associated with later-life memory level through higher mid-adulthood PA and lower rates of later-life hypertension, as well as with subsequent memory decline through higher mid-adulthood PA.

The conclusion, therefore, is that exercising in early or mid-adulthood provides us with a degree of protection for our later life cognitive health in addition to other health factors.

Which types of training might prove to be most effective in retaining cognitive processing or slowing down the age-related decline? A number of psychological tests have been included in the research to evaluate changes in cognition in several different physical exercise groups including resistance training, high intensity aerobic interval training, and moderate continuous aerobic training.

In one study the high intensive aerobic interval training group showed significant improvement in both reaction time and information processing. Also, the moderate continuous aerobic training group, likewise, showed significant improvement in executive cognitive tasks but the high intensity of group had the largest significant increase in terms of physical functioning.

Overall, the researchers found that moderate continuous aerobic training and resistance training proved to be superior to the high intensity training regime for older individuals in terms of their cognitive executive functioning.

The path forward is clear, physical exercise in any form that is comfortable, is beneficial later in life or currently. PA not only helps us maintain our physical mobility and health, it aids in forestalling cognitive decline and keeping that BDNF available to us when we need it.

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Other colleagues called Poison Control, worried that she maybe ingested a toxic alcohol. I was incensed: “What are you talking about? She has sepsis! Get the antibiotics! Get the fluids!” I was on a tear in the Emergency Department.

I spoke to the Poison Control colleague (likely a physician in training), and he recommended I make sure she didn’t have any toxic alcohol ingestion (like wood alcohol or antifreeze) given how acidic her blood was. I rolled my eyes. “She has sepsis. I am absolutely positive.” He replied politely and said, “That is our recommendation. You can do what you want.”

I ordered a CT scan of her abdomen, fully expecting to see multiple abscesses like they were before. I was shocked: her abdomen was completely clean. I couldn’t believe my eyes. And while I was totally convinced it would be negative, a little voice deep down inside me said, “Maybe just check for an antifreeze level…just in case.” So, I ordered one.

The ethylene glycol (i.e., antifreeze) level came back very high. It turns out that my patient tried to commit suicide by drinking antifreeze, and she had dangerously high acid levels as a result. I, therefore, came back into the hospital from home to put in a special tube so she can get emergency dialysis. She did well after that and was discharged to an inpatient psychiatry facility.

I frequently share this story to highlight my ICU Rule #6: “Your Ego Can Be Dangerous.”

We can never let our ego get in the way of patient care. We need to always keep a sense of humility when dealing with the patients for whom we care. In this case, the Poison Control trainee was absolutely right. My patient did not have sepsis, but indeed had ethylene glycol (antifreeze) toxicity. I was wrong, and he was right.

In other cases, the bedside nurse may make a suggestion that turns out to be right on; or, the medical student may do so. We cannot be full of our own self and ego to not take suggestions from everyone in the care team. Different clinicians bring different perspectives, and as leaders, we need to welcome those perspectives.

We are all on the same team with the same objective: to help heal our patients. If we ignore salient facts or suggestions because a nurse or tech or student or therapist suggested it, we are liable to place the patient in great danger. We have to resist this with every fiber of our being.

I shudder to think about what could have happened if I ignored that little voice inside me which said, “Dumb resident can’t tell me what to do!” and NOT ordered the antifreeze level. I shudder to think about what could have happened if I continued to feed my ego in this case. It is a lesson I have never forgotten, and I pray that I never, ever forget it in the future.

Along the same vein, I can’t tell you how many times I have said, “Call a Code!!!” while working in the ICU. When I say that, it means that a “CODE BLUE” needs to be called overhead in the hospital. When this is called, as many people who can respond come to where I am with my patient. It is a call for help.

Now, I have been practicing in the ICU for more than 16 years. I have been blessed with a lot of clinical experience. I am confident in the clinical abilities with which I have been blessed. But that does not mean that I am “too cool” to call for help, which is my ICU Rule #7: You Are Never “Too Cool” To Ask For Help.

Sometimes, I will call for help before even trying. For example, if I see that a patient needs to be placed on a ventilator and they have a challenging airway, I will call my Anesthesia colleagues from the very beginning. Yes, I have placed hundreds and hundreds of breathing tubes in the throats of patient. That doesn’t mean that I am the world expert at it. I want what’s best for my patient, and if that means have an Anesthesiologist rather than me place the airway, then so be it.

Now, does my ego get bruised a bit if my colleague easily does what I couldn’t do? Maybe. But, who cares about my ego? We are dealing with life and death in the ICU, and I am not going to stick a patient’s vein or artery multiple times – for example – so I can save face. If that was my family member, I would want the same for them.

Our egos can be dangerous. We are never too cool to ask for help. Yes, we have the experience. Yes, we are confident we can do the job right. But asking for help is not a sign of failure. We are all one team, and we have the same goal: healing our patient. And if that requires asking for help, then that is what we should do.

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