Cognitive rehabilitation can help older people clear up Covid-related brain fog

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Eight months after falling ill with covid-19, the 73-year-old woman could not remember what her husband had told her hours before. She would forget to remove the laundry from the dryer at the end of the cycle. She turned on the faucet of a sink and walked away.

Before covid, the woman did accounting for a local company. Now she couldn’t add single-digit numbers in her head.

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

What was happening? Like many people who contracted covid, this woman had trouble maintaining her attention, organizing activities and multitasking. She complained of brain fog. She didn’t feel like herself.

But this patient was lucky. Jill Jonas, an occupational therapist associated with Washington University School of Medicine in St. Louis who described her to me, provided cognitive rehabilitation to the patient and she is doing better.

Cognitive rehabilitation is therapy for people whose brains have been injured by concussions, traumatic accidents, strokes, or neurodegenerative diseases such as Parkinson’s disease. It is a series of interventions designed to help people recover from brain damage, if possible, and adapt to persistent 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 covid (symptoms that persist for months or more after an infection that cannot be explained by other medical conditions). According to the Centers for Disease Control and Prevention, approximately 1 in 4 older adults who survive covid have at least one persistent symptom.

Experts are excited about the potential of cognitive rehabilitation. “For the record, we see a lot of people [with long covid] make significant gains with the right kinds 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 treated 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 hospitalized in intensive care with covid develop such problems. 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.

Moreover, there is new evidence that older people are more likely to experience post-covid cognitive problems than younger people – a vulnerability attributed, in part, to the propensity of older people to have other cognitive problems. health. Cognitive challenges arise due to small blood clots, chronic inflammation, abnormal immune responses, brain damage such as strokes and hemorrhages, viral persistence, and covid-triggered neurodegeneration.

Getting help begins with an assessment by a rehabilitation professional to identify cognitive tasks that need attention and determine the severity of a person’s difficulties. One person may need help finding words when speaking, for example, while another may need help planning and another may not process information effectively. Several deficits can 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 themselves, according to Jason Smith, a rehabilitation psychologist at the University of Texas Southwestern Medical Center at Dallas: “Is it [deficit] show up for work? At home? Somewhere else? What activities are involved? What is most important to you and what do you want to work on? »

In an attempt to restore damaged brain circuits, patients may be prescribed a series of repetitive exercises. If attention is the issue, for example, a therapist might tap the table once or twice and ask a 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 so monotonous and someone can easily lose focus,” said Joe Giacino, professor of physical medicine and rehabilitation at Harvard Medical School. “But it’s a kind of muscle building for the brain.”

A therapist can 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 make connections where they can be made,” Giacino continued.

To address impairments 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 tasks down into steps, balancing activity with rest, figuring out how to conserve energy, and learning to slow down and assess 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 actually improves 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 went well 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 arise and why, they can prepare for them and they begin to see improvement,” said Johns University speech-language pathologist Lyana Kardanova Frantz. Hopkins. “A lot of my patients say, ‘I had no idea what [kind of therapy] could be so helpful.

Johns Hopkins has performed 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, said Dr. Alba Miranda Azola, co-director of Johns Hopkins’ post-acute COVID-19 team. When cognitive rehabilitation is recommended, patients typically see therapists once or twice a week for two to three months.

Before you can try this type of therapy, other issues may need to be addressed. “We want to make sure people are getting enough sleep, maintaining nutrition and hydration, and getting physical exercise that maintains blood flow and oxygenation to the brain,” Frantz said. “All of this impacts our cognitive function and our communication.”

Depression and anxiety – common companions for the seriously ill or disabled – also need attention. “A lot of times when people are struggling to deal with deficits, they focus on what they’ve been able to do in the past and really mourn that loss of efficiency,” Tremaine said. “There is also a big psychological component that needs to be managed.”

Medicare generally covers cognitive rehabilitation (patients may need to contribute a co-pay), but Medicare Advantage plans may differ in the type and duration of therapy they will approve and how much they will reimburse providers – a problem that can affect access to care.

Yet, noted Tremaine, “few people know about cognitive rehabilitation or understand what it does, and it remains underutilized.” She and other experts do not recommend digital brain training programs marketed to consumers as a substitute for practitioner-led cognitive rehabilitation due to the lack of individualized assessment, feedback and coaching.

Additionally, experts warn that while cognitive rehabilitation can help people with mild cognitive impairment, it is not appropriate for people with advanced dementia.

If you notice any concerning cognitive changes, ask your primary care doctor for a referral to an occupational therapist or speech-language pathologist, said Erin Foster, associate professor of occupational therapy, neurology and psychiatry at Washington University School of Medicine in St. Louis. Be sure to ask therapists if they have experience dealing with memory and thinking issues in daily life, she recommended.

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

We look forward to hearing from readers about the questions you’d like answered, the issues you’ve had with your care, and the advice you need for dealing with the health care system. Visit khn.org/columnists to submit your requests or advice.

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