Cognitive profile following COVID-19 infection: Clinical predictors leading to neuropsychological impairment

Speech-language pathology approaches to neurorehabilitation in acute care during COVID-19: Capitalizing on neuroplasticity

Neurologic manifestations associated with a coronavirus disease 2019 (COVID‐19) diagnosis are common and often occur in severe and critically ill patients. In these patients, the neurologic symptoms are confounded by critical care conditions, such as acute respiratory distress syndrome (ARDS). Patients with dual diagnoses of COVID‐19 and neurologic changes such as myopathy, polyneuropathy, and stroke are likely at a higher risk of experiencing deficits with swallowing, communication, and/or cognition. Speech‐language pathologists are an integral part of both the critical care and neurologic disorders multi‐disciplinary teams, offering valuable contributions in the evaluation, treatment, and management of these areas. Patients in intensive care units (ICUs) who require mechanical ventilation often experience difficulty with communication and benefit from early speech‐language pathology intervention to identify the most efficient communication methods with the medical team and caregivers. Moreover, patients with neurologic manifestations may present with cognitive‐linguistic impairments such as aphasia, thereby increasing the need for communication‐based interventions. Difficulties with voice and swallowing after extubation are common, often requiring frequent treatment sessions, possibly persisting beyond ICU discharge. After leaving the ICU, patients with COVID‐19 often experience physical, cognitive, and mental health impairments collectively called post‐intensive care syndrome. This is often a lengthy road as they progress toward full recovery, requiring continued speech‐language pathology treatment after hospital discharge, capitalizing on the principles of neuroplasticity.

Molecular Insights into SARS-CoV2-Induced Alterations of the Gut/Brain Axis

For a yet unknown reason, a substantial share of patients suffering from COVID-19 develop long-lasting neuropsychiatric symptoms ranging from cognitive deficits to mood disorders and/or an extreme fatigue. We previously reported that in non-neural cells, angiotensin-1 converting enzyme 2 (ACE2), the gene coding for the SARS-CoV2 host receptor, harbors tight co-expression links with dopa-decarboxylase (DDC), an enzyme involved in the metabolism of dopamine. Here, we mined and integrated data from distinct human expression atlases and found that, among a wide range of tissues and cells, enterocytes of the small intestine express the highest expression levels of ACE2, DDC and several key genes supporting the metabolism of neurotransmitters. Based on these results, we performed co-expression analyses on a recently published set of RNA-seq data obtained from SARS-CoV2-infected human intestinal organoids. We observed that in SARS-CoV2-infected enterocytes, ACE2 co-regulates not only with DDC but also with a specific group of genes involved in (i) the dopamine/trace amines metabolic pathway, (ii) the absorption of microbiota-derived L-DOPA and (iii) the absorption of neutral amino acids serving as precursors to neurotransmitters. We conclude that in patients with long COVID, a chronic infection and inflammation of small intestine enterocytes might be indirectly responsible for prolonged brain alterations.

Monthlong Intubated Patient with Life-Threatening COVID-19 and Cerebral Microbleeds Suffers Only Mild Cognitive Sequelae at 8-Month Follow-up: A Case Report

OBJECTIVE

To elaborate on possible cognitive sequelae related to COVID-19, associated cerebrovascular injuries as well as the general consequences from intensive care. COVID-19 is known to have several, serious CNS-related consequences, but neuropsychological studies of severe COVID-19 are still rare.

METHODS

M., a 45-year-old man, who survived a severe COVID-19 disease course including Acute Respiratory Distress Syndrome (ARDS), cerebral microbleeds, and 35 days of mechanical ventilation, is described. We elaborate on M's recovery and rehabilitation process from onset to the 8-month follow-up. The cognitive functions were evaluated with a comprehensive screening battery at 4 weeks after extubation and at the 8-month follow-up.

RESULTS

Following extubation, M. was delirious, reported visual hallucinations, and had severe sleeping difficulties. At about 3 months after COVID-19 onset, M. showed mild to moderate deficits on tests measuring processing speed, working memory, and attention. At assessments at 8 months, M. performed better, with results above average on tests measuring learning, memory, word fluency, and visuospatial functions. Minor deficits were still found regarding logical reasoning, attention, executive functioning, and processing speed. There were no lingering psychiatric symptoms. While M. had returned to a part-time job, he was not able to resume previous work-tasks.

CONCLUSION

This case-study demonstrates possible cognitive deficits after severe COVID-19 and emphasizes the need of a neuropsychological follow-up, with tests sensitive to minor deficits. The main findings of this report provide some support that the long-term prognosis for cognition in severe COVID-19 may be hopeful.

Post-acute cognitive and mental health outcomes amongst COVID-19 survivors: early findings and a call for further investigation

Click here to view the Original Article by R. Méndez et al

A Controlled Study of Continuous Lumbar Drainage of Fluid and Lumbar Puncture Drainage for Aneurysmal SAH after Intracranial Aneurysm Clipping

Objective

To analyze the different effects of Continuous Lumbar Drainage of fluid and lumbar puncture drainage for aneurysmal subarachnoid hemorrhage (SAH) after intracranial aneurysm clipping.

Method

Seventy-five patients with aneurysmal SAH who underwent aneurysm clipping were retrospectively analyzed and were divided into two groups according to the different postoperative drainage methods. The lumbar spine group received lumbar puncture drainage, and the lumbar cistern group received lumbar pool continuous drainage to compare the efficacy.

Result

The time to normalize intracranial pressure and headache relief after drainage treatment in the lumbar cistern group was shorter than that in the lumbar spine group. The GOS score was higher than that in the lumbar spine group, and the cerebral artery flow velocity and NIHSS score were significantly lower than those in the lumbar spine group (P < 0.05). The total effective rate of drainage treatment was 76.32% in the lumbar cistern group, which was higher than that in the lumbar spine group (54.05%) (P < 0.05). The total complication rate was 18.42% in the lumbar cistern group, which was lower than that in the lumbar spine group (40.54%) (P < 0.05).

Conclusion

Continuous Lumbar Drainage of fluid after intracranial aneurysm clipping for aneurysmal SAH can control symptoms more rapidly, reduce neurological deficits, and improve prognosis than lumbar puncture. Also, the drainage is safer and more widely used.

A Framework for Addressing Clients' Functional Cognitive Deficits After COVID-19

Occupational therapy's focus on functional cognition offers a distinct approach to the assessment of and intervention for occupational performance deficits that may follow coronavirus disease 2019 (COVID-19). Although the majority of people survive COVID-19, many people experience persistent functional cognitive sequelae severe enough to interfere with occupational performance. After COVID-19, people may be categorized as either (1) those who experience severe or critical illness requiring hospitalization or (2) those with mild to moderate presentations of the virus without hospitalization. A third group of those who do not have ongoing signs of active infection but who experience new, lasting, or deteriorating symptoms has begun to emerge and may represent a distinct COVID-19 long-haul syndrome. By following the Occupational Therapy Practice Framework and using established processes for occupational therapy assessment and treatment of functional cognition, occupational therapy practitioners can tailor assessments and interventions to meet clients' needs.

Dementia and COVID-19, a Bidirectional Liaison: Risk Factors, Biomarkers, and Optimal Health Care

Cognitive impairment following SARS-CoV-2 infection is being increasingly recognized as an acute and possibly also long-term sequela of the disease. Direct viral entry as well as systemic mechanisms such as cytokine storm are thought to contribute to neuroinflammation in these patients. Biomarkers of COVID-19-induced cognitive impairment are currently lacking, but there is some limited evidence that SARS-CoV-2 could preferentially target the frontal lobes, as suggested by behavioral and dysexecutive symptoms, fronto-temporal hypoperfusion on MRI, EEG slowing in frontal regions, and frontal hypometabolism on 18F-FDG-PET. Possible confounders include cognitive impairment due to hypoxia and mechanical ventilation and post-traumatic stress disorder. Conversely, patients already suffering from dementia, as well as their caregivers, have been greatly impacted by the disruption of their care caused by COVID-19. Patients with dementia have experienced worsening of cognitive, behavioral, and psychological symptoms, and the rate of COVID-19-related deaths is disproportionately high among cognitively impaired people. Multiple factors, such as difficulties in remembering and executing safeguarding procedures, age, comorbidities, residing in care homes, and poorer access to hospital standard of care play a role in the increased morbidity and mortality. Non-pharmacological interventions and new technologies have shown a potential for the management of patients with dementia, and for the support of their caregivers.

Cognitive Impairment After COVID-19-A Review on Objective Test Data

Objective: The aim was to conduct a review on the literature on objective cognitive impairment in patients after COVID-19. Methods: We performed a literature review and searched Ovid Medline in February 2021 based on a PECO scheme. Results: Twelve articles met all inclusion criteria. Total patient sample was <1,000. All studies on global cognitive function found impairment, ranging from 15 to 80% of the sampled patients. Seven studies on attention and executive functions reported impairment, with varying results depending on sub-domain and different tests. Three out of four studies reported memory difficulties, with two studies reporting short-term memory deficits. Although results indicate possible language impairment, only one study used domain-specific language tasks. Two out of four studies on visuospatial function did not report any impairment. Conclusion: Patients with recent SARS-CoV-2 infection appear to experience global cognitive impairment, impairment in memory, attention and executive function, and in particular verbal fluency. Based on the current results, we recommend clinicians to evaluate the need for cognitive assessment of patients with a recent COVID-19 infection, regardless of the severity of the disease, treatment methods and length of ICU stay. We need studies with larger sample and control group.

A systematic review of neuropsychological and psychiatric sequalae of COVID-19: implications for treatment

PURPOSE OF REVIEW

COVID-19 impacts multiple organ systems and is associated with high rates of morbidity and mortality. Pathogenesis of viral infection, co-morbidities, medical treatments, and psychosocial factors may contribute to COVID-19 related neuropsychological and psychiatric sequelae. This systematic review aims to synthesize available literature on psychiatric and cognitive characteristics of community-dwelling survivors of COVID-19 infection.

RECENT FINDINGS

Thirty-three studies met inclusion/exclusion criteria for review. Emerging findings link COVID-19 to cognitive deficits, particularly attention, executive function, and memory. Psychiatric symptoms occur at high rates in COVID-19 survivors, including anxiety, depression, fatigue, sleep disruption, and to a lesser extent posttraumatic stress. Symptoms appear to endure, and severity of acute illness is not directly predictive of severity of cognitive or mental health issues. The course of cognitive and psychiatric sequelae is limited by lack of longitudinal data at this time. Although heterogeneity of study design and sociocultural differences limit definitive conclusions, emerging risk factors for psychiatric symptoms include female sex, perceived stigma related to COVID-19, infection of a family member, social isolation, and prior psychiatry history.

SUMMARY

The extant literature elucidates treatment targets for cognitive and psychosocial interventions. Research using longitudinal, prospective study designs is needed to characterize cognitive and psychiatric functioning of COVID-19 survivors over the course of illness and across illness severity. Emphasis on delineating the unique contributions of premorbid functioning, viral infection, co-morbidities, treatments, and psychosocial factors to cognitive and psychiatric sequelae of COVID-19 is warranted.

Post-covid syndrome: a review of pathophysiology, neuropsychiatric manifestations and treatment perspectives

In the context of the COVID-19 pandemic, healthcare is faced with several new problems, one of which is a post-covid syndrome. Symptoms in many COVID-19 survivors can persist for a long time, significantly affecting the quality of life and work performance. All of the above makes post-covid syndrome a socially significant disease, requires dynamic follow-up of such patients, and rehabilitation programs development. We are currently at the stage of accumulating knowledge about the SARS-CoV-2 pathophysiology and morphogenesis and its long-term consequences. This article discusses neuropsychiatric aspects of the post-covid syndrome: pathogenetic hypotheses, clinical features, and potentially promising treatment strategies.

Cognitive and behavioral manifestations in SARS-CoV-2 infection: not specific or distinctive features?

Patients with COVID-19 are increasingly reported to suffer from a wide range of neurological complications, affecting both the central and peripheral nervous system. Among central manifestations, cognitive and behavioral symptoms are to date not exhaustively detailed. Furthermore, it is not clear whether these represent a combination of non-specific complications of a severe systemic disease, not differing from those usually seen in patients suffering from heterogenous pathological conditions affecting the central nervous system, or instead, they are a peculiar expression of COVID-19 neurotropism; in other words, if the infection has a coincidental or causal role in such patients. We examined both hypotheses, reporting opposite points of view, with the aim to stimulate discussion and raise awareness of the topic.

Neuropsychological Pattern in a Series of Post-Acute COVID-19 Patients in a Rehabilitation Unit: Retrospective Analysis and Correlation with Functional Outcomes

Intensive Care Unit delirium, insomnia, anxiety, and frontal/dysexecutive disorders have been described following COVID-19 infection. The aim of this case study was to re-evaluate the neuropsychological pattern in a series of patients with COVID-19 outcomes. We retrospectively evaluated 294 patients admitted to the Istituti Clinici Scientifici Maugeri of Lumezzane (Brescia) (May-September 2020). Neuropsychological assessment was available for 12 patients. We extracted clinical, functional data (FIM and Barthel Index score) and neuropsychological tests (MMSE, Trail making a-b, verbal fluency test, digit span, prose memory test, Frontal Assessment Battery, clock drawing test, Rey-Osterrieth complex figure, Tower of London test). The results were analyzed by Spearman (rho) correlation. Six patients presented dysexecutive alterations even in the presence of normal overall cognitive functioning. Forward digit span score was directly correlated to FIM value at admission (p = 0.015) and inversely correlated to delta FIM (p = 0.030) and delta Barthel Index (p = 0.025). In our experience, subclinical cognitive alterations were present in 4% of patients recovering from COVID-19 pneumonia. The possible correlation between verbal memory and frontal functions, and the degree of functional impairment at admission and its subsequent improvement, underscores the importance of an adequate cognitive evaluation and rehabilitation.

Intrinsic Capacity Assessment by a Mobile Geriatric Team During the Covid-19 Pandemic

In the autumn of 2020, the second wave of the COVID-19 pandemic hit Europe. In this context, because of the insufficient number of beds in geriatric COVID units, non-geriatric wards were confronted with a significant number of admissions of geriatric patients. In this perspective article, we describe the role of a mobile geriatric team in the framework of the COVID-19 pandemic and specifically how it assisted other specialists in the management of hospitalized geriatric patients by implementing a new approach: the systematic assessment and optimization of Intrinsic Capacity functions. For each patient, assessed by this consultative team, an individualized care plan, including an anticipated end-of-life decision-making process, was established. Intensity of care was most often not stated by considering chronological age but rather the comorbidity burden, the frailty status, and the patient's wishes. Further studies are needed to determine if this mobile geriatric team approach was beneficial in terms of mortality, length of stay, or functional, psychological, and cognitive outcomes in COVID-19 geriatric patients.

[Neuropsychiatric sequelae of the COVID-19 pandemic]

The COVID-19 pandemic has a significant impact on mental health. On the one hand, fears about one's economic situation, own health and the health of others can lead to psychosocial consequences. On the other hand, social isolation through physical distancing can affect mental health. Finally, the infection itself can lead to psychiatric and neuropsychiatric symptoms as part of a systemic manifestation. In this paper, different mechanisms are presented, which can lead directly or indirectly to neuropsychological and psychopathological symptoms in the context of the COVID-19 pandemic.

Brain Metabolic Correlates of Persistent Olfactory Dysfunction after SARS-Cov2 Infection

We aimed to evaluate the brain hypometabolic signature of persistent isolated olfactory dysfunction after SARS-CoV-2 infection. Twenty-two patients underwent whole-body [18F]-FDG PET, including a dedicated brain acquisition at our institution between May and December 2020 following their recovery after SARS-Cov2 infection. Fourteen of these patients presented isolated persistent hyposmia (smell diskettes olfaction test was used). A voxel-wise analysis (using Statistical Parametric Mapping software version 8 (SPM8)) was performed to identify brain regions of relative hypometabolism in patients with hyposmia with respect to controls. Structural connectivity of these regions was assessed (BCB toolkit). Relative hypometabolism was demonstrated in bilateral parahippocampal and fusiform gyri and in left insula in patients with respect to controls. Structural connectivity maps highlighted the involvement of bilateral longitudinal fasciculi. This study provides evidence of cortical hypometabolism in patients with isolated persistent hyposmia after SARS-Cov2 infection. [18F]-FDG PET may play a role in the identification of long-term brain functional sequelae of COVID-19.

Infection Mechanism of SARS-COV-2 and Its Implication on the Nervous System

In late December 2019, multiple atypical pneumonia cases resulted in severe acute respiratory syndrome caused by a pathogen identified as a novel coronavirus SARS-CoV-2. The most common coronavirus disease 2019 (COVID-19) symptoms are pneumonia, fever, dry cough, and fatigue. However, some neurological complications following SARS-CoV-2 infection include confusion, cerebrovascular diseases, ataxia, hypogeusia, hyposmia, neuralgia, and seizures. Indeed, a growing literature demonstrates that neurotropism is a common feature of coronaviruses; therefore, the infection mechanisms already described in other coronaviruses may also be applicable for SARS-CoV-2. Understanding the underlying pathogenetic mechanisms in the nervous system infection and the neurological involvement is essential to assess possible long-term neurological alteration of COVID-19. Here, we provide an overview of associated literature regarding possible routes of COVID-19 neuroinvasion, such as the trans-synapse-connected route in the olfactory pathway and peripheral nerve terminals and its neurological implications in the central nervous system.

COVID-19 and the Pediatric Nervous System: Global Collaboration to Meet a Global Need

The coronavirus disease 2019 (COVID-19) pandemic has affected mortality and morbidity across all ages, including children. It is now known that neurological manifestations of COVID-19, ranging from headaches to stroke, may involve the central and/or peripheral nervous system at any age. Neurologic involvement is also noted in the multisystem inflammatory syndrome in children, a pediatric condition that occurs weeks after infection with the causative virus of COVID-19, severe acute respiratory syndrome coronavirus 2. Knowledge about mechanisms of neurologic disease is scarce but rapidly growing. COVID-19 neurologic manifestations may have particularly adverse impacts on the developing brain. Emerging data suggest a cohort of patients with COVID-19 will have longitudinal illness affecting their cognitive, physical, and emotional health, but little is known about the long-term impact on affected children and their families. Pediatric collaboratives have begun to provide important initial information on neuroimaging manifestations and the incidence of ischemic stroke in children with COVID 19. The Global Consortium Study of Neurologic Dysfunction in COVID-19-Pediatrics, a multinational collaborative, is working to improve understanding of the epidemiology, mechanisms of neurological manifestations, and the long-term implications of COVID-19 in children and their families.

Association Between Psychological Distress, Cognitive Complaints, and Neuropsychological Status After a Severe COVID-19 Episode: A Cross-Sectional Study

Background: Cognitive complaints are frequent after COVID-19 but their clinical determinants are poorly understood. This study aimed to explore the associations of objective cognitive performances and psychological distress with cognitive complaints in COVID-19 survivors. Materials and Methods: Patients previously hospitalized for COVID-19 in a university hospital during the first wave of COVID-19 pandemic in France were followed-up at 1 month after their admission. Cognitive complaints were self-reported and standardized instruments were used to assess neuropsychological status (Digit Symbol Substitution Test, Semantic Verbal Fluency Test, Mini Mental Status Examination) and psychological distress (Hospital Anxiety and Depression Scale, HADS). Multivariable analyses were adjusted for age, sex, admission in intensive care unit (ICU) and need for oxygen and C-reactive protein. Results: One hundred patients (34% women, median age: 60 years [interquartile range: 49-72)] completed the neuropsychological assessment at follow-up. In multivariable analyses, cognitive complaints at 1-month were associated with greater HADS score (OR for one interquartile range: OR: 1.96, 95% CI: 1.08-3.57) and older age (OR: 1.05, 95% CI: 1.01-1.09) and, negatively, with admission in ICU (OR: 0.22, 95% CI: 0.05-0.90). In contrast, none of the objective neuropsychological test scores was significantly associated with cognitive complaints. Exploratory analysis showed that cognitive complaints were associated with both anxiety and depressive symptoms. Discussion: These preliminary results suggest that cognitive complaints at 1 month after a hospitalization for COVID-19 are associated with psychological distress, independently of objective neuropsychological status. Anxiety and depression symptoms should be systematically screened in patients presenting with cognitive complaints after a severe COVID-19 episode.