Editor’s note: Find the latest news and guidance about COVID-19 at the Medscape Coronavirus Resource Center.
Eight months after she contracted covid-19, the 73-year-old couldn’t remember what her husband had said to her hours before. She may have forgotten to take the laundry out of the dryer at the end of the cycle. She turned on the faucet at the sink and left.
Before covid, a woman was doing bookkeeping at a local business. Now she couldn’t add single digits in her head.
Was this the earliest stage of dementia exposed by covid? No. When the therapist assessed the woman’s cognitive abilities, her performance was normal.
What’s happened? Like many people who contracted covid, this woman had difficulty maintaining focus, organizing activities, and multitasking. She complained of fog in her head. She was out of her mind.
But this patient was lucky. Jill Jonas, the occupational therapist at the Washington University School of Medicine in St. Louis, who described her to me, is doing cognitive rehabilitation on the patient, and she is getting better.
Cognitive rehabilitation is a therapy for people whose brains have been damaged as a result of a concussion, injury accidents, stroke, or neurodegenerative conditions such as Parkinson’s disease. This is a set of interventions designed to help people recover from traumatic brain injuries, if possible, and adapt to ongoing cognitive impairment. Services are typically provided by speech and occupational therapists, neuropsychologists, and neurorehabilitation experts.
Recently, some medical centers offer cognitive rehabilitation for patients with long-term covid (symptoms that persist for months or longer after infection that cannot be explained by other diseases). According to the Centers for Disease Control and Prevention, about 1 in 4 older people who survive COVID-19 have at least one persistent symptom.
Experts are enthusiastic about the potential of cognitive rehabilitation. “Oddly enough, we see a large number of people [with long covid] achieve significant gains with the right interventions,” said Monique Tremaine, director of neuropsychology and cognitive rehabilitation at the JFK Johnson Hackensack Meridian Health Rehabilitation Institute in New Jersey.
Among the post-COVID cognitive complaints that are being considered are problems with attention, speech, information processing, memory, and visuospatial orientation. A recent review in JAMA Psychiatry found that up to 47% of patients admitted to intensive care with covid developed this kind of problem. Meanwhile, a new review in Nature Medicine found brain fog was 37% more likely in non-hospitalized COVID survivors than matched peers who had no known Covid infections.
In addition, evidence is emerging that older people are more likely to experience cognitive problems after coronavirus than younger people, a vulnerability partly attributed to older people’s predisposition to other illnesses. Cognitive problems arise from small blood clots, chronic inflammation, abnormal immune responses, brain injuries such as strokes and hemorrhages, virus persistence, and covid-induced neurodegeneration.
Getting help begins with an assessment by a rehabilitation specialist to pinpoint cognitive tasks that need attention and determine the severity of a person’s difficulties. One person may need help finding words during a conversation, for example, while another may need help planning and a third may not process information efficiently. Several deficiencies may be present at the same time.
What follows is an attempt to understand how patients’ cognitive problems affect their daily lives. According to Jason Smith, a rehabilitation psychologist at the University of Texas Southwestern Medical Center at Dallas, among the questions therapists will ask are: [deficit] showing up at work? Houses? Somewhere else? What activities are affected? What is most important to you and what do you want to work on?
To try to repair damaged brain circuits, patients may be given a series of repetitive exercises. For example, if attention is the problem, the therapist may tap the table with his finger once or twice and ask the patient to do the same, repeating this several times. This type of intervention is known as restorative cognitive rehabilitation.
“It’s not easy because it’s so monotonous and someone can easily lose focus,” said Joe Giachino, a professor of physical medicine and rehabilitation at Harvard Medical School. “But it’s a kind of muscle building for the brain.”
The therapist may then ask the patient to do two things at the same time: for example, repeat the tapping task while answering questions about their personal experience. “Now the brain has to divide attention – a much more difficult task – and you are building connections where they can be built,” Giachino continued.
To address the disturbances that interfere with people’s daily lives, the therapist will work on practical strategies with patients. Examples include making lists, setting alarms or reminders, breaking down tasks into milestones, balancing activity with rest, figuring out how to conserve energy, and learning how to slow down and assess what needs to be done before taking action.
A growing body of evidence shows that “older people can learn to use these strategies and it really improves their daily lives,” said Alyssa Lanzi, research assistant professor of cognitive rehabilitation at the University of Delaware.
Along the way, patients and therapists discuss what worked well and what didn’t, and practice useful skills such as using calendars or notepads as memory aids.
“Because patients better understand where difficulties arise and why, they can prepare for them and begin to see improvements,” says Lyana Kardanova Franz, a speech pathologist at Johns Hopkins University. “Many of my patients say, ‘I had no idea about it.’ [kind of therapy] can be very helpful.”
Johns Hopkins conducts neuropsychiatric evaluations of patients who come to his post-COVID clinic. About 67% have mild to moderate cognitive dysfunction at least three months after exposure, said Dr. Alba Miranda Azola, co-lead of the Johns Hopkins University Post-Acute COVID-19 Group. When cognitive rehabilitation is recommended, patients usually meet with therapists once or twice a week for two to three months.
Other problems may need to be addressed before this type of therapy can be tried. “We want to make sure people get enough sleep, maintain their nutrition and hydration, and get exercise that keeps blood flowing and brain oxygenated,” Franz said. “All of this affects our cognitive function and communication.”
Depression and anxiety – frequent companions of the seriously ill or disabled – also need attention. “Often when people are trying to deal with a deficit, they focus on what they could have done in the past and really mourn the loss of efficiency,” Tremaine said. “There’s also a big psychological component that needs to be managed.”
Medicare usually covers cognitive rehabilitation (patients may be required to pay a co-payment), but Medicare Advantage plans can vary in the type and length of therapy they approve and the amount they reimburse providers—an issue that can affect access to care.
However, Tremaine noted, “not many people know about cognitive rehabilitation or understand what it does, and it remains underused.” She and other experts do not recommend digital brain training programs sold to consumers as a substitute for practitioner-led cognitive rehabilitation due to a lack of individualized assessment, feedback, and coaching.
In addition, experts warn, although cognitive rehabilitation can help people with mild cognitive impairment, it is not suitable for people with advanced dementia.
If you notice cognitive changes that cause concern, ask your primary care physician for a referral to an occupational therapist or speech therapist, says Erin Foster, assistant professor of occupational therapy, neurology, and psychiatry at the Washington University School of Medicine in St. Louis. Louis. Be sure to ask therapists if they have experience dealing with memory and thinking problems in everyday life, she recommended.
“If there is a medical center with a rehabilitation unit in your area, contact them and ask for a referral to cognitive rehabilitation,” said Smith of UT Southwestern Medical Center. “The professional discipline that helps the most in cognitive rehabilitation will be rehabilitation medicine.”