Eight months after falling ill with Covid-19, the 73-year-old woman could not remember what her husband had told her a few hours earlier. At the end of the cycle, she forgot to take the laundry out of the dryer. She would turn on the tap at a sink and walk away.
Before covid, the woman did the bookkeeping for a local company. Now she couldn’t add single-digit numbers in her head.
Was it the earliest stage of dementia exposed by covid? No. When a therapist assessed the woman’s cognition, her scores were normal.
What was going on? Like many people who have contracted Covid, this woman struggled to sustain attention, organize activities, and multitask. She complained of brain fog. She didn’t feel like herself.
But this patient was lucky. Jill Jonas, an occupational therapist at Washington University School of Medicine in St. Louis, who described her to me, has given the patient cognitive rehabilitation and she is getting better.
Cognitive rehabilitation is therapy for people whose brains have been injured by concussions, traumatic accidents, strokes, or neurodegenerative disorders such as Parkinson’s disease. It is a series of interventions designed to help people recover from brain injuries, if possible, and adapt to ongoing cognitive impairment. 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 patients with long-term covid (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 ongoing symptom.
Experts are excited about the potential of cognitive rehabilitation. “Anecdotally we see quite a few people [with long covid] making significant gains with the right types of interventions,” said Monique Tremaine, director of neuropsychology and cognitive rehabilitation at the JFK Johnson Rehabilitation Institute at Hackensack Meridian Health in New Jersey.
Among the post-covid cognitive complaints that are addressed are problems with attention, language, information processing, memory and visual-spatial orientation. A recent review in JAMA Psychiatry found that up to 47% of patients admitted to intensive care with covid developed these types of problems. Meanwhile, a new review in Nature Medicine found that brain fog was 37% more likely in unhospitalized covid survivors than similar peers who had no known covid infections.
There is also mounting evidence that seniors are more likely to have cognitive challenges after Covid than younger people — a vulnerability attributed in part to older adults’ tendency to have other medical conditions. Cognitive problems arise from small blood clots, chronic inflammation, abnormal immune responses, brain injuries such as strokes and bleeding, viral persistence and neurodegeneration caused by covid.
Getting help starts with an assessment by a rehabilitation professional to identify cognitive tasks that need attention and determine the severity of a person’s problems. For example, one person needs help finding words while speaking, another needs help planning, and yet another cannot process information efficiently. Multiple deficiencies can be present at the same time.
Next comes an attempt to understand how patients’ cognitive problems affect their daily lives. One of the questions therapists will ask, according to Jason Smith, a rehabilitation psychologist at the University of Texas Southwestern Medical Center at Dallas: “Is this [deficit] show up at work? Home? Elsewhere? Which 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 prescribed a series of repetitive exercises. For example, if attention is the problem, a therapist might tap the table once or twice with a finger and ask a patient to do the same and repeat it several times. This type of intervention is known as restorative cognitive rehabilitation.
“It’s not easy because it’s so monotonous and one can easily lose their focus,” said Joe Giacino, a professor of physical medicine and rehabilitation at Harvard Medical School. “But it’s kind of muscle building for the brain.”
A therapist can then ask the patient to do two things at once: repeat the typing task and, for example, answer questions about their personal background. “Now the brain has to divide attention — a much more demanding task — and you build connections where they can be built,” Giacino continued.
To address limitations that hinder people’s daily lives, a therapist will work with patients on practical strategies. Examples include creating lists, setting alarms or reminders, dividing tasks into steps, balancing activity with rest, figuring out how to conserve energy and learning to slow down, and assessing what needs to be done before taking action.
A growing body of evidence shows that “older adults can learn to use these strategies and it may actually improve their daily lives,” said Alyssa Lanzi, a research assistant professor who studies 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 reminders.
“As patients become more aware of where problems are occurring and why, they can prepare for them and begin to see improvement,” says 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 so helpful.’”
Johns Hopkins has conducted neuropsychiatric studies on patients who come to the post-covid clinic. About 67% have mild to moderate cognitive impairment at least three months after infection, said Dr. Alba Miranda Azola, co-director of the Post-Acute COVID-19 team at Johns Hopkins. When cognitive rehabilitation is recommended, patients usually meet with therapists once or twice a week for two to three months.
Before this type of therapy can be attempted, other issues may need to be addressed. “We want to make sure people get enough sleep, maintain nutrition and hydration, and get exercise that maintains blood flow and oxygenation to the brain,” Frantz said. “All of these affect our cognitive function and communication.”
Depression and anxiety — common companions for people who are seriously ill or disabled — also need attention. “When people struggle to manage their deficits, they often focus on what they could do in the past and really mourn that 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 make a co-payment), but Medicare Advantage plans may differ in the type and duration of therapy they approve and how much they reimburse health care providers — an issue that can affect health outcomes. access to care.
Still, Tremaine noted, “not many people know about cognitive rehabilitation or understand what it does, and it remains underused.” They and other experts do not recommend digital brain training programs marketed to consumers as a replacement for physician-led cognitive rehabilitation due to the lack of individualized assessment, feedback, and coaching.
Experts also warn that cognitive rehabilitation may help people with mild cognitive impairment, but is not appropriate for those with advanced dementia.
If you notice cognitive changes from care, ask for a referral from your primary care physician to an occupational or speech therapist, said Erin Foster, an associate professor of occupational therapy, neurology and psychiatry at Washington University School of Medicine in St. Louis. Ask therapists if they have experience with memory and thinking problems in everyday life, she recommended.
“If there is a medical center in your area that has a rehabilitation unit, contact them and ask for a referral to cognitive rehabilitation,” says Smith of UT Southwestern Medical Center. “The professional discipline that is most helpful in cognitive rehabilitation is becoming rehabilitation medicine.”
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