Clinical features and cognitive sequelae in COVID-19: a retrospective study on N=152 patients

The risk of cognitive decline and dementia in older adults diagnosed with COVID-19: A systematic review and meta-analysis

BACKGROUND

Cognitive impairment can be caused by infections with various pathogens, including SARS-CoV-2. Research has yet to determine the true incidence and course of cognitive impairment in older adults following COVID-19. Furthermore, research has theorised that COVID-19 is associated with dementia progression and diagnosis but this association has yet to be fully described.

METHODS

A systematic review was registered in Prospero and conducted on the databases PubMed, Embase, Ovid, CENTRAL and Cochrane Library. Studies reporting cognitive impairment and dementia outcomes in post-acute and post-COVID-19 patients aged ≥65 years, and which included control data, were included in this review.

RESULTS

15,124 articles were identified by the search strategy. After eliminating duplicate titles and completing title, abstracts and full-text review, 18 studies were included comprising of 412,957 patients with COVID-19 (46.63% male) and 411,929 patients without COVID-19 (46.59% male). The overall mean Montreal Cognitive Assessment (MoCA) score in COVID-19 patients was 23.34 out of 30 (95% CI [22.24, 24.43]). indicating cognitive impairment. The overall proportion of patients identified as having new onset cognitive impairment was 65% (95% CI [44, 81]). Subgroup analyses indicated that time since infection significantly improves overall MoCA score and reduces proportion of patients with cognitive impairment.

CONCLUSION

This study indicates that cognitive impairment may be an important sequela of COVID-19. Further research with adequate sample sizes is warranted regarding COVID-19's association with new-onset dementia and dementia progression, and the effect of repeat infections. There is a need for development of diagnostic and management protocols for COVID-19 patients with cognitive impairment.

Meta-analysis of Cognitive Function Following Non-severe SARS-CoV-2 Infection

To effectively diagnose and treat subjective cognitive symptoms in post-acute sequalae of COVID-19 (PASC), it is important to understand objective cognitive impairment across the range of acute COVID-19 severity. Despite the importance of this area of research, to our knowledge, there are no current meta-analyses of objective cognitive functioning following non-severe initial SARS-CoV-2 infection. The aim of this meta-analysis is to describe objective cognitive impairment in individuals with non-severe (mild or moderate) SARS-CoV-2 cases in the post-acute stage of infection. This meta-analysis was pre-registered with Prospero (CRD42021293124) and utilized the PRISMA checklist for reporting guidelines, with screening conducted by at least two independent reviewers for all aspects of the screening and data extraction process. Fifty-nine articles (total participants = 22,060) with three types of study designs met our full criteria. Individuals with non-severe (mild/moderate) initial SARS-CoV-2 infection demonstrated worse objective cognitive performance compared to healthy comparison participants. However, those with mild (nonhospitalized) initial SARS-CoV-2 infections had better objective cognitive performance than those with moderate (hospitalized but not requiring ICU care) or severe (hospitalized with ICU care) initial SARS-CoV-2 infections. For studies that used normative data comparisons instead of healthy comparison participants, there was a small and nearly significant effect when compared to normative data. There were high levels of heterogeneity (88.6 to 97.3%), likely reflecting small sample sizes and variations in primary study methodology. Individuals who have recovered from non-severe cases of SARS-CoV-2 infections may be at risk for cognitive decline or impairment and may benefit from cognitive health interventions.

[Interaction of somatic findings and psychiatric symptoms in COVID-19. A scoping review]

An infection with SARS-CoV‑2 can affect the central nervous system, leading to neurological as well as psychiatric symptoms. In this respect, mechanisms of inflammation seem to be of much greater importance than the virus itself. This paper deals with the possible contributions of organic changes to psychiatric symptomatology and deals especially with delirium, cognitive symptoms, depression, anxiety, posttraumatic stress disorder and psychosis. Processes of neuroinflammation with infection of capillary endothelial cells and activation of microglia and astrocytes releasing high amounts of cytokines seem to be of key importance in all kinds of disturbances. They can lead to damage in grey and white matter, impairment of cerebral metabolism and loss of connectivity. Such neuroimmunological processes have been described as a organic basis for many psychiatric disorders, as affective disorders, psychoses and dementia. As the activation of the glia cells can persist for a long time after the offending agent has been cleared, this can contribute to long term sequalae of the infection.

Cognitive dysfunction in post-COVID-19 condition: Mechanisms, management, and rehabilitation

The long-term effects of COVID-19 on cognitive function have become an area of increasing concern. This paper provides an overview of characteristics, risk factors, possible mechanisms, and management strategies for cognitive dysfunction in post-COVID-19 condition (PCC). Prolonged cognitive dysfunction is one of the most common impairments in PCC, affecting between 17% and 28% of the individuals more than 12 weeks after the infection and persisting in some cases for several years. Cognitive dysfunctions can be manifested as a wide range of symptoms including memory impairment, attention deficit, executive dysfunction, and reduced processing speed. Risk factors for developing PCC, with or without cognitive impairments, include advanced age, preexisting medical conditions, and the severity of acute illness. The underlying mechanisms remain unclear, but proposed contributors include neuroinflammation, hypoxia, vascular damage, and latent virus reactivation not excluding the possibility of direct viral invasion of the central nervous system, illustrating complex viral pathology. As the individual variation of the cognitive impairments is large, a neuropsychological examination and a person-centered multidimensional approach are required. According to the World Health Organization, limited evidence on COVID-19-related cognitive impairments necessitates implementing rehabilitation interventions from established practices of similar conditions. Psychoeducation and compensatory skills training are recommended. Assistive products and environmental modifications adapted to individual needs might be helpful. In specific attention- and working memory dysfunctions, cognitive training-carefully monitored for intensity-might be effective for people who do not suffer from post-exertional malaise. Further research is crucial for evidence-based interventions specific to COVID-19-related cognitive impairments.

Alzheimer's disease risk after COVID-19: a view from the perspective of the infectious hypothesis of neurodegeneration

In light of the rising evidence of the association between viral and bacterial infections and neurodegeneration, we aimed at revisiting the infectious hypothesis of Alzheimer's disease and analyzing the possible implications of COVID-19 neurological sequelae in long-term neurodegeneration. We wondered how SARS-CoV-2 could be related to the amyloid-β cascade and how it could lead to the pathological hallmarks of the disease. We also predict a paradigm change in clinical medicine, which now has a great opportunity to conduct prospective surveillance of cognitive sequelae and progression to dementia in people who suffered severe infections together with other risk factors for Alzheimer's disease.

COVID-19 pandemic in the intensive care unit: Psychological implications and interventions, a systematic review

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic produced changes in intensive care units (ICUs) in patient care and health organizations. The pandemic event increased patients’ risk of developing psychological symptoms during and after hospitalisation. These consequences also affected those family members who could not access the hospital. In addition, the initial lack of knowledge about the virus and its management, the climate of fear and uncertainty, the increased workload and the risk of becoming infected and being contagious, had a strong impact on healthcare staff and organizations. This highlighted the importance of interventions aimed at providing psychological support to ICUs, involving patients, their relatives, and the staff; this might involve the reorganisation of the daily routine and rearrangement of ICU staff duties.

AIM

To conduct a systematic review of psychological issues in ICUs during the COVID-19 pandemic involving patients, their relatives, and ICU staff.

METHODS

We investigated the PubMed and the ClinicalTrials.gov databases and found 65 eligible articles, upon which we commented.

RESULTS

Our results point to increased perceived stress and psychological distress in staff, patients and their relatives and increased worry for being infected with severe acute respiratory syndrome coronavirus-2 in patients and relatives. Furthermore, promising results were obtained for some psychological programmes aiming at improving psychological measures in all ICU categories.

CONCLUSION

As the pandemic limited direct inter-individual interactions, the role of interventions using digital tools and virtual reality is becoming increasingly important. All considered, our results indicate an essential role for psychologists in ICUs.

Relationship between Reaction Times and Post-COVID-19 Symptoms Assessed by a Web-Based Visual Detection Task

Long-COVID is a clinical condition in which patients affected by SARS-CoV-2 usually report a wide range of physical and cognitive symptoms from 3 to 6 months after the infection recovery. The aim of the current study was to assess the link between self-reported long-COVID symptoms and reaction times (RTs) in a self-administered Visual Detection Task (VDT) in order to identify the predictor symptoms of the slowing in reaction times to determine attention impairment. In total, 362 participants (age (mean ± S.D.: 38.56 ± 13.14); sex (female-male: 73.76-26.24%)) responded to a web-based self-report questionnaire consisting of four sections: demographics, disease-related characteristics, and medical history questions. The final section consisted of a 23 item 5-point Likert-scale questionnaire related to long-term COVID-19 symptoms. After completing the questionnaire, subjects performed a VDT on a tablet screen to assess reaction times (RTs). An exploratory factorial analysis (EFA) was performed on the 23 long-COVID symptom questions, identifying 4 factors (cognition, behavior, physical condition, presence of anosmia and/or ageusia). The most important predictors of RTs were cognition and physical factors. By dissecting the cognitive and physical factors, learning, visual impairment, and headache were the top predictors of subjects' performance in the VDT. Long-COVID subjects showed higher RTs in the VDT after a considerable time post-disease, suggesting the presence of an attention deficit disorder. Attention impairment due to COVID-19 can be due to the presence of headaches, visual impairments, and the presence of cognitive problems related to the difficulty in learning new activities. The link between the slowing of reaction times and physical and cognitive symptoms post-COVID-19 suggests that attention deficit disorder is caused by a complex interaction between physical and cognitive symptoms. In addition, the study provides evidence that RTs in a VDT represent a reliable measure to detect the presence of long-COVID neurological sequelae.

Monitoring cognitive and psychological alterations in COVID-19 patients: A longitudinal neuropsychological study

BACKGROUND

SARS-COV-2 infection has been associated to long-lasting neuropsychiatric sequelae, including cognitive deficits, that persist after one year. However, longitudinal monitoring has been scarcely performed. Here, in a sample of COVID-19 patients, we monitor cognitive, psychological and quality of life-related profiles up to 22 months from resolution of respiratory disease.

METHODS

Out of 657 COVID-19 patients screened at Manzoni Hospital (Lecco, Italy), 22 underwent neuropsychological testing because of subjective cognitive disturbances at 6 months, 16 months, and 22 months. Tests of memory, attention, and executive functions were administered, along with questionnaires for depressive and Post-traumatic stress disorder (PTSD) symptoms, psychological well-being and quality of life. Cross-sectional descriptives, correlational, as well as longitudinal analyses considering COVID19-severity were carried out. A preliminary comparison with a sample of obstructive sleep apneas patients was also performed.

RESULTS

Around 50% of COVID-19 patients presented with cognitive deficits at t0. The most affected domain was verbal memory. Pathological scores diminished over time, but a high rate of borderline scores was still observable. Longitudinal analyses highlighted improvements in verbal and non-verbal long term memory, as well as attention, and executive functioning. Depression and PTSD-related symptoms were present in 30% of patients. The latter decreased over time and were associated to attentional-executive performance.

CONCLUSIONS

Cognitive dysfunctions in COVID-19 patients may extend over 1 year, yet showing a significant recovery in several cases. Cognitive alterations are accompanied by a significant psychological distress. Many patients displaying borderline scores, especially those at higher risk of dementia, deserve clinical monitoring.

Psychological and Cognitive Functioning Among Patients Receiving Outpatient Rehabilitation for Post-COVID Sequelae: An Observational Study

OBJECTIVES

To describe the characteristics of individuals receiving outpatient rehabilitation for post-acute sequelae of SARS-CoV-2 infection (PASC). Further, to examine factors associated with variation in their psychological and cognitive functioning and health-related quality of life.

DESIGN

Observational study.

SETTING

Outpatient COVID-19 recovery clinic at a large, tertiary, urban health system in the US.

PARTICIPANTS

COVID-19 survivors with persistent sequelae (N=324).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Multivariable logistic and linear regression models were used to examine factors associated with COVID survivors' experience of severe anxiety, severe depression, post-traumatic stress disorder (PTSD), cognitive impairment, and self-reported health-related quality of life.

RESULTS

About 38% of survivors seeking care for their persistent COVID symptoms suffered from severe anxiety, 31.8% from severe depression, 43% experiencing moderate to severe PTSD symptomology, and 17.5% had cognitive impairment. Their health-related quality of life was substantially lower than that of the general population (-26%) and of persons with other chronic conditions. Poor and African American/Black individuals experienced worse psychological and cognitive sequelae after COVID19 infection, even after controlling for age, sex, initial severity of the acute infection, and time since diagnosis.

CONCLUSIONS

Evidence of consistent disparities in outcomes by the patients' race and socioeconomic status, even among those with access to post-acute COVID rehabilitation care, are concerning and have significant implications for PASC policy and program development.

Cognitive Deficits among Individuals Admitted to a Post-Acute Pneumological Rehabilitation Unit in Southern Italy after COVID-19 Infection

(1) Background: We investigated the differences in the neuropsychological profile as well as the pneumological and motor functions in two groups of patients admitted to rehabilitation who received different respiratory support during their COVID-19 infection. (2) Methods: Group-1 (n = 18; 15 male, median age 67.5) consisted of patients who received non-invasive mechanical ventilation; Group-2 (n = 19; 16 male, median age 63) consisted of patients who received invasive mechanical ventilation. All patients underwent a neuropsychological assessment including Mini-Mental State Examination (MMSE), Frontal Assessment Battery (FAB), and the Repeatable Battery for the Assessment of Neuropsychological Status (R-BANS) to evaluate the patients' cognition. Depression and anxiety were also measured at admission and discharge to rehabilitation. (3) Results: At admission, patients impaired at MMSE were 44% in Group-1 and 5% in Group-2, while patients impaired at FAB were 88% in Group-1 and 26% in Group-2. Wilcoxon's effect size revealed meaningful differences between groups for FAB, R-BANS global score, immediate and delayed memory, and attention-coding task, with Group-2 performing better than Group-1 across all measures. At discharge, 52% of the 25 patients re-assessed still had mild to moderate cognitive deficits, while 19% had depression and 35% had anxiety. (4) Conclusions: Patients who received oxygen therapy experienced higher levels of acute and chronic stress compared to those who benefitted from invasive mechanical ventilation. Despite patients showing a meaningful improvement at discharge, cognitive impairment persisted in a great number of patients; therefore, long-term neuropsychological follow-up and treatment for COVID-19 patients are recommended.

Association between serologically confirmed COVID-19 infection and cognitive functioning in community dwelling older adults

Introduction

COVID-19 infection can impact the central nervous system, and is often associated with cognitive decline. However, there are no studies linking serologically confirmed COVID-19 infection with objectively assessed cognitive functioning. We explored whether presence of SARS-CoV-2 antibodies account for variability in participants' scores on a neuropsychological assessment.

Methods

In this cross-sectional study participants were 657 (mean age = 72.97; SD = 6.07 years; women = 47.7%) individuals randomly selected from the general population of the canton of Zurich and included in the Corona Immunitas study. We conducted serological tests between October 2020 and May 2021 to detect and quantify SARS-CoV-2 antibodies in peripheral venous blood samples. We assessed cognitive function, vaccination status (vaccinated; not vaccinated), number of health conditions, and demographic variables between January and August 2021. We studied the association between seropositivity and global cognitive function and five cognitive domains (language expression, language comprehension, temporal orientation, spatial orientation, and memory) with linear regression models. Based on SARS-CoV-2 antibodies and vaccination status, we stratified participants into three groups: No SARS-CoV-2 antibodies (N = 402); SARS-CoV-2 antibodies due to vaccination (N = 218); history of SARS-CoV-2 infection and no vaccination (N = 37).

Results

In the regression model adjusted for age, sex, educational level, and number of health conditions, compared to those without SARS-CoV-2 antibodies, those with SARS-CoV-2 antibodies due to vaccination had better global cognitive functioning (Standardized beta = 0.10; 95% CI = 0.02; 0.17), and those with SARS-CoV-2 antibodies due to infection had poorer cognitive functioning (Standardized beta = -0.10; 95% CI = -0.18; -0.03). Regarding cognitive domains, compared to those without SARS-CoV-2 antibodies, those with SARS-CoV-2 antibodies due to infection scored more poorly on language comprehension and temporal orientation, and those with SARS-CoV-2 antibodies due to vaccination scored better on memory.

Discussion

By linking serologically confirmed presence of SARS-CoV-2 antibodies to poorer global cognitive functioning in community dwelling older adults we strengthen existing evidence in support of cognitive decline related to COVID-19. Given the large number of infected older adults, and the endurance of the pandemic, our results highlight the need to address COVID-19 related cognitive decline in the clinical and public health areas of prevention, diagnosis, and treatment.

Cognitive Impairment after Post-Acute COVID-19 Infection: A Systematic Review of the Literature

The present study aims to provide a critical overview of the literature on the relationships between post-acute COVID-19 infection and cognitive impairment, highlighting the limitations and confounding factors. A systematic search of articles published from 1 January 2020 to 1 July 2022 was performed in PubMed/Medline. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only studies using validated instruments for the assessment of cognitive impairment were included. Out of 5515 screened records, 72 studies met the inclusion criteria. The available evidence revealed the presence of impairment in executive functions, speed of processing, attention and memory in subjects recovered from COVID-19. However, several limitations of the literature reviewed should be highlighted: most studies were performed on small samples, not stratified by severity of disease and age, used as a cross-sectional or a short-term longitudinal design and provided a limited assessment of the different cognitive domains. Few studies investigated the neurobiological correlates of cognitive deficits in individuals recovered from COVID-19. Further studies with an adequate methodological design are needed for an in-depth characterization of cognitive impairment in individuals recovered from COVID-19.

The association between objective cognitive measures and ecological-functional outcomes in COVID-19

Background

Cognitive dysfunctions, both subjective and detectable at psychometric testing, may follow SARS-CoV-2 infection. However, the ecological-functional relevance of such objective deficits is currently under-investigated. This study thus aimed at investigating the association between objective cognitive measures and both physical and cognitive, ecological-functional outcomes in post-COVID-19.

Methods

Forty-two COVID-19-recovered individuals were administered the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA). The Functional Independence Measure (FIM) was adopted to assess functional-ecological, motor/physical (FIM-Motor) and cognitive (FIM-Cognitive) outcomes at admission (T0) and discharge (T1).

Results

When predicting both T0/T1 FIM-total and-Motor scores based on MMSE/MoCA scores, premorbid risk for cognitive decline (RCD) and disease-related features, no model yielded a significant fit. However, the MoCA - but not the MMSE significantly predicted T0/T1 FIM-Cognitive scores. The MoCA was significantly related only to T0/T1 FIM-Cognitive Memory items.

Discussion

Cognitive measures are not associated with physical/motor everyday-life outcomes in post-COVID-19 patients. The MoCA may provide an ecological estimate of cognitive functioning in this population.

Cognitive Behavioral Psychotherapy after COVID-19: Opportunities and Prospects

This article reviews domestic and foreign studies on cognitive behavioral therapy techniques in treating cognitive disorders in former COVID-19 patients. Coronavirus-induced cognitive disorders include damage to the nervous system as a result of respiratory distress syndrome, cytokine storm, cerebral vascular thrombosis, direct exposure to SARS-Cov2, and inadequate immune response. Concomitant mental illnesses include autistic disorders, dementia, cognitive decline, eating disorders, suicidal behavior, anxiety, depression, post-traumatic stress, insomnia, etc. Diagnostic methods usually take into account a complex violation of mental activities, e.g., short memory span, attention deficiency, slow thinking, and various affective disorders. As a result, diagnostic methods can be divided into several areas: neuropsychological diagnostics of cognitive functions (MMSE, MOCA, FAB), identification of inadequate attitudes and behavior (WCQ, SPB, DAS), identification of violations of daily activity (The Barthel Scale), identification of psychological and psychiatric issues (Hospital Anxiety and Depression Scale, State-Trait Anxiety Inventory, Hamilton Rating Scale for Depression). Psychological care for former COVID-19 patients relies on some basic principles. Cognitive behavioral psychotherapy techniques aim at correcting cognitive distortions, teaching relaxation and self-regulation, improving problem-solving skills, and restoring cognitive functions. 

Psychiatric symptoms subsequent to COVID-19 and their association with clinical features: A retrospective investigation

This study explores the association between psychiatric symptoms following COVID-19 and demographic, disease-related and premorbid clinical confounders. Global cognition, depression, anxiety and PTSD features were assessed in 152 post-COVID-19 patients, subdivided into being at risk for brain disorders or not. In both groups, clinically meaningful depression, anxiety and PTSD symptoms were mildly-to-moderately frequent (4-45%). No demographic or clinical variables predicted psychiatric measures (except for lower age predicting higher anxiety levels). Depression, anxiety and PTSD measures were associated among each other. Hence, depression-, anxiety- and PTSD-spectrum disturbances in COVID-19 survivors are likely to be unassociated with disease-related and premorbid features.

Cognitive phenotyping of post-infectious SARS-CoV-2 patients

Background

SARS-CoV-2 infection entails neuroinvasive, neuroinflammatory, and treatment-related features accounting for cognitive deficits in COVID-19-recovered patients. Although screening for such dysfunctions in this population is considered clinically relevant, contributions to cognitive phenotyping including premorbid and disease-related confounders are scarcely represented. This study thus aimed at describing the cognitive outcome at the function-/domain-level of post-infectious SARS-CoV-2 patients being already at risk (RCD +) or not (RCD −) for cognitive decline.

Methods

Fifty-four COVID-19-recovered individuals were classified as either RCD + or RCD − according to medical records. The Mini-Mental State Examination (MMSE), Addebrooke Cognitive Examination-Revised (ACE-R), Frontal Assessment Battery (FAB), and Attentive Matrices (AM) were administered (N = 54, 34, 28, and 28 patients, respectively).

Results

Prevalence of defective (cutoff = 24.89) MMSE scores was 24.3% in RCD + patients and 5.9% in the RCD − group. ACE-R-total below cutoff scores were less frequent (RCD + : 5.4%; RCD − : 5.9%). Abnormal performances at the FAB an AM were respectively detected in 18.9% and 8.1% of RCD + patients and 0% and 11.8% of the RCD − group. Within the ACE-R subtests, those assessing orientation, attention, and fluency were the most frequently impaired in both groups. Disease-related variables were mostly unassociated with cognitive measures.

Discussion

Both RCD + and RCD − COVID-19-recovered individuals might show cognitive deficits within the dysexecutive-inattentive and amnesic spectrum. Non-instrumental, executive/attentive dysfunctions are predominant in this population and can be detected by both screening and domain-specific psychometric tests—although the latter might be more sensitive in RCD − patients.

[The state of cognitive functions in patients with coronavirus infection in the acute period of the disease (outbreaks in 2020-2022)]

OBJECTIVE

To assess the state of cognitive functions in patients in the acute period of coronavirus infection with pneumonia during periods of hospitalization in 2020-2022.

MATERIAL AND METHODS

The study included 3 groups of people of different ages. The first and second groups are inpatients in the acute period of coronavirus infection with viral pneumonia during treatment in a hospital in Krasnoyarsk. Group 1 was hospitalized in the period December 2020 - March 2021. The second group was hospitalized in the period November 2021 - January 2022. The control group consisted of clinically healthy individuals. MMSE, MoCA, FAB, CDT were used to assess the neuropsychological status. Anxiety and depression were assessed using HADS. Patients in the groups were tested on the first day after stabilization of the condition, then again for discharge or transfer to another hospital. The control group was tested once.

RESULTS

Statically significant cognitive impairments were detected in patients with coronavirus infection with viral pneumonia in the acute period of the disease, both at admission and at discharge, compared with the control group. Patients admitted for the period December 2020 - March 2021 had more pronounced cognitive impairment than patients admitted for the period November 2021 - January 2022. Anxiety and depression were not detected on HADS.

CONCLUSION

Coronavirus infection with viral pneumonia causes cognitive impairment in patients in the acute period of the disease. The severity of changes of cognitive functions was different depending on outbreaks of infection, which may probably be due to a mutation of the virus for the period 2020-2022.