Cognitive problems are among the most persistent and common lasting effects of Covid. Now some patients are getting help from brain rehab programs.
A radiographer at Northwestern Memorial Hospital performs a CT brain scan. PHOTO: NORTHWESTERN MEDICINE
By Sumathi Reddy
The newest patients in cognitive rehabilitation programs didn’t suffer concussions, traumatic brain injuries or strokes.
Cognitive problems are some of the most persistent and common long-term symptoms that people struggle with months after getting Covid. Patients report short-term memory problems, slow processing speeds, poor word recall and difficulty multitasking. To help them, doctors at medical centers including Mayo Clinic, Yale and Johns Hopkins are
Starting to refer some patients to cognitive rehabilitation more typically used for patients with concussions and other traumatic brain injuries.
“Even if the mechanism causing symptoms is different, the problems are often the same,” says Thomas Bergquist, a clinical neuropsychologist who focuses on neurocognitive disorders at Mayo’s brain rehabilitation clinic. Many patients have had difficulties returning to work. “They can get through the day, but they are just not nearly as efficient as they used to be and they’re much more tired,” says Dr. Bergquist.
At Mayo’s clinic, a rehabilitation team helps patients with pacing and energy conservation strategies, such as dividing up a longer task into small increments with breaks. Simple techniques like taking notes, using a planner or app to record information, and setting electronic reminders can help people improve memory and organization. Other tactics include reducing screen time, proper sleep, managing stress and exercise.
People still experiencing symptoms weeks or months after their initial Covid diagnosis are commonly referred to as long Covid patients, and make up an estimated 10% or more of all Covid-19 cases, according to studies and experts. Many initially had mild cases and weren’t hospitalized.
Igor Koralnik performs a neurological exam on a patient atthe Neuro Covid-19 clinic at Northwestern Memorial Hospital in Chicago.
Neurological symptoms are among the most common lingering effects. In a study published in March in the journal Annals of Clinical and Translational Neurology, Northwestern researchers found that 85% of 100 nonhospitalized long Covid patients experienced four or more neurologic symptoms more than six weeks after their infection. The most common symptom was “brain fog,” experienced by 81% of the participants.
It’s unclear what exactly is causing the symptoms. But some scientists believe it may be caused by inflammation triggered by the virus and damage to tiny blood vessels in the brain. Another possible explanation is that the immune system mistakenly attacks brain cells. Stress and mood changes may also result in biological changes to the body.
The brain fog that patients describe shares similarities with post-traumatic brain injuries as well as the brain fog associated with chemotherapy and chronic fatigue syndrome, says Igor Koralnik, chief of neuro-infectious diseases and global neurology at Northwestern Medicine in Chicago. He oversees the Neuro Covid-19 Clinic at Northwestern Memorial Hospital and is senior author of the recent study looking at neurologic symptoms in long Covid patients.
Patients who perform below average on cognitive tests and feel they are impaired in their daily activities get a cognitive behavioral evaluation, says Dr. Koralnik. Based on the results, some patients are referred to cognitive rehab.
Andrew McCoy is among them. The 55-year-old tested positive for the virus that causes Covid-19 in October and says he started experiencing cognitive issues a month later.
Suddenly, he could no longer remember common words. He had trouble remembering events from the previous day and where he had placed items. “My short-term memory was horrific,” says Mr. McCoy, a vice president for a Fortune 500 life-science company. “It affected my daily life in such an incredibly negative way. I literally couldn’t tell you what I had for dinner the evening prior.”
Andrew McCoy suered memory and other cognitive dificulties after getting Covid-19 in October. He says cognitive rehab has helped him learn strategies and tools.
A series of neuropsychology tests showed he had cognitive deficits, he says. Dr. Koralnik referred him to Shirley Ryan AbilityLab, a physical medicine and rehabilitation research hospital in Chicago. There he met with a speech-language pathologist as well as occupational and physical therapists.
He learned to journal his daily events and now routinely fills eight to 10 pages in his journal every day. “Journaling in real time helps me keep up with my thoughts and complex information coming from multiple sources,” he says. He meditates briefly throughout the day. He takes pictures of his car when he parks in large lots. He tries to place things in the same place and learned to concentrate on using simpler words to avoid problems with word recall. “I’m more disciplined and habitual about things,” he says.
Mr. McCoy says he’s made significant progress over the past month, although an evaluation at Northwestern in January showed he still had some deficits in short-term memory and processing speed.
Now, he says he feels about 90% back to normal using the coping mechanisms he learned in rehab. “People just have to adapt and find what works for them,” he says. “The strategies really help. You can be a really high-functioning person one day and then really have these sorts of deficits and you do need help.”
Cognitive screening in post-Covid patients can help identify patients who need care. At Johns Hopkins in Baltimore, workers do cognitive screening tests on the phone with Covid-19 patients from a pulmonary clinic roughly four months after infection, says Tracy Vannorsdall, a clinical neuropsychologist at Johns Hopkins School of Medicine. “Nearly two-thirds of our patients are producing one or more low scores on cognitive testing and are really struggling” when compared with age-adjusted norms, she says.
“They are performing much more poorly than we would expect, particularly when it comes to processing speed as well as learning and memory,” adds Dr. Vannorsdall.
Once doctors identify a problem, they conduct more in-depth neuropsychological exams and refer patients to cognitive rehabilitation therapy. That involves meeting with neuropsychologists, rehabilitation psychologists, speech language therapists and psychiatrists, depending on a patient’s needs.
Yale developed a post-Covid neurology clinic in September after seeing how many patients were coming in with neurological complications, says Serena Spudich, chief of neuroinfectious diseases and global neurology at Yale and a lead researcher of the Covid Mind Study, which studies Covid’s effects on the brain. “They expected to bounce back and they didn’t,” she says.
Dr. Spudich says Yale started the clinic thinking it would be short-term. Months later, there’s so much demand it is fully booked into the summer.
Patients with concentration and memory problems can get detailed testing and are then referred to cognitive rehabilitation. “I’ve seen people improve,” she says. “It’s not solving the underlying problems but helping them develop tricks and techniques to manage things that they’re having trouble with.”
For now, Dr. Spudich says, most patients are at least stable. Yale researchers are following up to 100 Covid patients with ongoing neurological issues for five years to see if symptoms worsen or develop into persistent brain disorders, says Dr. Spudich. “The long term follow-up is really important to make sure that whatever we’re seeing will go away,” says Dr. Spudich.
What’s Causing Post-Covid Brain Problems?
Scientists trying to understand the cause of Covid-related cognitive problems are looking closely at brain inflammation and blood-vessel damage.
In a New England Journal of Medicine study published in December, National Institutes of Health researchers looked at the brains of 19 deceased people who had been infected with the virus that causes Covid-19. Most had been relatively healthy and hadn’t been hospitalized from Covid-19, but had died suddenly.
Autopsies of the brain found damage from leaky brain blood vessels, says Avindra Nath, clinical director at the NIH’s National Institute of Neurological Disorders and Stroke and senior author of the study.
“We saw inflammation in the brain and we saw vascular damage,” says Dr. Nath. “The small blood vessels were leaking blood products into the brain and we found inflammation around the blood vessels.”
In a study by Columbia University researchers published in the journal JAMA Psychiatry in March, researchers reviewed the autopsy results of the brains of about 40 sick and hospitalized Covid-19 patients and had similar findings. They found that generalized inflammation can disrupt the chemicals necessary for communication between brain cells, says Maura Boldrini, associate professor of psychiatry at Columbia University Vagelos College of Physicians and Surgeons and first author of the study. They also found
that the coronavirus damages small blood vessels in the brain, observing big and small clots in the brains.
Microscopic clots can result in less oxygen going to the brain region, resulting in cognitive impairment, says Dr. Boldrini. Now, the researchers hope to compare the brains of the deceased Covid-19 patients with scans and cognitive testing in living long Covid patients to see if there are similarities.
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