Cognitive rehabilitation can help older adults clear COVID brain fog

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Eight months after falling ill with covid-19, the 73-year-old woman did not remember what her husband had told her a few hours earlier. She forgot to take the clothes out of the dryer at the end of the cycle. She turned on a sink faucet and left.

Before covid, the woman had been doing accounting for a local business. Now, she couldn’t add single digit numbers in her head.

Was it the earliest stage of dementia, unmasked by covid? No. When a therapist evaluated the woman’s cognition, her scores were normal.

What’s going on? Like many people who have contracted COVID, this woman had difficulty sustaining attention, organizing activities, and multitasking. She complained of brain fog. She didn’t feel like herself.

But this patient was lucky. jill jonasAn occupational therapist associated with Washington University School of Medicine in St. Louis, who described her to me, has been providing cognitive rehabilitation to the patient and she is improving.

Cognitive rehabilitation is a therapy for people whose brains have been injured by concussions, traumatic accidents, strokes, or neurodegenerative conditions such as Parkinson’s disease. It is a set of interventions designed to help people recover from brain injuries, if possible, and adapt to ongoing cognitive decline. Services are typically provided by speech and occupational therapists, neuropsychologists, and neurorehabilitation experts.

In a recent development, some medical centers are offering cognitive rehabilitation to long covid patients (symptoms that persist for several months or more after an infection that cannot be explained by other medical conditions). According to the Centers for Disease Control and Prevention, about 1 in 4 older adults who survive Covid have at least one persistent symptom.

Experts are excited about the potential of cognitive rehabilitation. “Anecdotally, we are seeing a good number of people [with long covid] make significant progress with the right kinds of interventions,” said Monique Tremaine, director of neuropsychology and cognitive rehabilitation at Hackensack Meridian Health’s JFK Johnson Rehabilitation Institute in New Jersey.

Among the post-Covid cognitive complaints being addressed are problems with attention, language, information processing, memory, and visuospatial orientation. a recent review in JAMA Psychiatry found that up to 47% of patients hospitalized in intensive care with covid developed problems of this type. Meanwhile, a new review in Nature Medicine found that brain fog was 37% more likely in non-hospitalized covid survivors than in comparable peers who had no known covid infections.

In addition, there is emerging evidence that older people are more likely to experience post-Covid cognitive challenges than younger people, a vulnerability attributed, in part, to older adults’ propensity to have other medical conditions. Cognitive challenges arise due to small blood clots, chronic inflammation, abnormal immune responses, brain injuries such as strokes and hemorrhages, viral persistence, and covid-induced neurodegeneration.

Getting help begins with an evaluation by a rehabilitation professional to identify the cognitive tasks that need attention and determine the severity of a person’s difficulties. One person may need help finding words while speaking, for example, while another may need help with planning, and another may not be processing information efficiently. Several deficits may be present at the same time.

Next comes an effort to understand how patients’ cognitive problems affect their daily lives. Among the questions therapists will ask, according to Jason Smithrehabilitation psychologist at the University of Texas Southwestern Medical Center in Dallas: “Is this [deficit] showing up at work? At home? Somewhere else? What activities are being affected? What is the most important thing for you and what do you want to work on?

To try to restore brain circuits that have been damaged, patients may be prescribed a series of repetitive exercises. If the problem is attention, for example, a therapist might tap a finger on the table once or twice and ask the patient to do the same, repeating it several times. This type of intervention is known as restorative cognitive rehabilitation.

“It’s not easy because it’s very monotonous and someone can easily lose focus,” he said. joe giacino, professor of physical medicine and rehabilitation at Harvard Medical School. “But it is a kind of muscular development for the brain.”

A therapist could then ask the patient to do two things at once: repeat the tapping task while answering questions about their personal history, for example. “Now the brain has to divide attention, a much more demanding task, and you’re building connections where they can be built,” Giacino continued.

To address deficiencies that interfere with people’s daily lives, a therapist will work on practical strategies with patients. Examples include making lists, setting alarms or reminders, breaking down tasks into steps, balancing activity with rest, discovering how to conserve energy and learning to slow down, and evaluating what needs to be done before acting.

A growing body of evidence shows that “older adults can learn to use these strategies and that they actually improve their daily lives,” he said. Alyssa Lanziresearch assistant professor studying cognitive rehabilitation at the University of Delaware.

Along the way, patients and therapists discuss what worked and what didn’t, and practice helpful skills such as using calendars or notebooks as memory aids.

“As patients become more aware of where difficulties occur and why, they can prepare for them and begin to see improvements,” said Lyana Kardanova Frantz, a speech therapist at Johns Hopkins University. “A lot of my patients say, ‘I had no idea about this [kind of therapy] could be very useful.

Johns Hopkins has been conducting neuropsychiatric exams on patients who come to its post-Covid clinic. About 67% have mild to moderate cognitive dysfunction at least three months after being infected, he said. Dr. AS Alba Miranda is not following anyone., co-leader of the Johns Hopkins post-acute COVID-19 team. When cognitive rehabilitation is recommended, patients typically meet with therapists once or twice a week for two to three months.

Before this type of therapy can be tried, other issues may need to be addressed. “We want to make sure that people get enough sleep, maintain their nutrition and hydration, and engage in physical exercise that maintains blood flow and oxygenation to the brain,” Frantz said. “All of them impact our cognitive function and communication.”

Depression and anxiety, common companions of the seriously ill or disabled, also need attention. “A lot of times when people struggle to manage deficits, they focus on what they were able to do in the past and really mourn that loss of efficiency,” Tremaine said. “There’s also a huge psychological component that needs to be managed.”

Medicare generally covers cognitive rehabilitation (patients may need to contribute a copay), but Medicare Advantage plans may differ in the type and duration of therapy they’ll approve and how much they’ll reimburse providers, an issue that can affect the access to care.

Still, 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 marketed to consumers as a substitute for professionally led cognitive rehabilitation due to a lack of individualized assessment, feedback, and coaching.

Also, experts caution, while cognitive rehabilitation can help people with mild cognitive impairment, it’s not appropriate for people with advanced dementia.

If you notice concerning cognitive changes, ask your primary care doctor for a referral to a speech or occupational therapist, advised Erin Foster, an associate professor of occupational therapy, neurology and psychiatry at Washington University School of Medicine in St. Luis. Be sure to ask therapists if they have experience treating memory and thinking problems in daily life, she recommended.

“If there’s a medical center in your area with a rehabilitation department, contact them and ask for a referral for cognitive rehabilitation,” said Smith, of UT Southwestern Medical Center. “The professional discipline that helps the most with cognitive rehabilitation is going to be rehabilitation medicine.”

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