Covert Subclinical Neurocognitive Sequelae During the Rehabilitation Course of Severe Coronavirus Disease 2019

Abstract

Apart from respiratory symptoms, encephalopathy and a range of central nervous system complications have been described in coronavirus disease 2019. However, there is a lack of published literature on the rehabilitative course and functional outcomes of severe coronavirus disease 2019 with encephalopathy. In addition, the presence of subclinical neurocognitive sequelae during postacute rehabilitation has not been described and may be underrecognized by rehabilitation providers. We report the rehabilitative course of a middle-aged male patient with severe coronavirus disease 2019 who required intensive care and mechanical ventilation. During postacute inpatient rehabilitation for severe intensive care unit–related weakness, an abnormal cognitive screen prompted brain magnetic resonance imaging, which revealed destructive leukoencephalopathy. Subsequently, detailed psychometric evaluation revealed significant impairments in the domains of processing speed and executive function. After 40 days of intensive inpatient rehabilitation, he was discharged home with independent function. This report highlights the need for an increased awareness of covert subclinical neurocognitive sequelae, the role of comprehensive rehabilitation, and value of routine cognitive screening therein and describes the neurocognitive features in severe COVID-19.

Seeing through brain fog: disentangling the cognitive, physical, and mental health sequalae of COVID-19.

“…Research conducted prior to the worldwide spread of COVID-19 clearly established that associations exist between impaired cognitive function and both anxiety disorders 30 , and depression 31 , although the relationship between fatigue and speci c cognitive de cits seems rather less clear 32,33 . Several recent studies have reported an increased risk of psychiatric disturbance in patients recovering from COVID-19 20,34−36 , although others have reported no association between cognitive outcomes and psychiatric symptoms 25 , including anxiety 17,24 depression 17,24 and fatigue 24 .…”

“…This issue has gained import in recent months as poorly speci ed terms like 'brain fog' have entered both common parlance and the scienti c literature describing 'long COVID' or COVID 'long-haulers' [10][11][12][13] . Unfortunately, the widespread use of 'blunt' screening tools such as the Mini Mental State Examination (MMSE 14 ) and the Montreal Cognitive Assessment (MOCA 15 ) to evaluate the effects of COVID-19 infection only adds to this confusion, as both were designed to detect the emergence of dementia in the elderly, rather than to provide a comprehensive picture of cognitive performance [16][17][18][19][20] . For example, in one study, 28% of recovered COVID-19 patients scored below the established cut off of 26 (for dementia) on the MoCA, compared to only 17% of controls, although median MoCA scores in the patients were not statistically different from those of the controls 20 .…”

“…Second, how does the emergence of cognitive de cits following COVID-19 infection relate to the severity of the primary infection? Several preliminary studies have suggested that, in patients who required hospitalised treatment, cognitive de cits following COVID-19 infection are dependent on the level of medical assistance received 1,22 and the degree of in ammation 21 with severe infections being associated with signi cant cognitive de cits 17,18,23 although cognitive impairments have also been reported in asymptomatic patients 16 , and one small study reported no correlation with hospitalization and cognitive impairments 24 . Given current knowledge about long-lasting cognitive de cits from post ICU syndrome, we might expect a worse cognitive outcome with more severe COVID-19 illness [7][8][9] .…”

Delirium and long term cognition in critically ill patients

“…In a single center case series, 28 patients were seen six weeks after hospital discharge, and 57% had mild cognitive impairment on completing the Montreal Cognitive Assessment 38. In one case report, a 39 year old patient transferred for inpatient physical rehabilitation for profound ICU acquired weakness was later determined to have moderate to severe cognitive impairment (processing speed, waking memory, visuospatial processing, and executive function) 39. As a result, a multimodal cognitive rehabilitation strategy was incorporated into his physical rehabilitation, demonstrating the diverse rehabilitation challenges considering likely occult and subtle cognitive changes in covid-19 survivors 39.…”

“…In one case report, a 39 year old patient transferred for inpatient physical rehabilitation for profound ICU acquired weakness was later determined to have moderate to severe cognitive impairment (processing speed, waking memory, visuospatial processing, and executive function) 39. As a result, a multimodal cognitive rehabilitation strategy was incorporated into his physical rehabilitation, demonstrating the diverse rehabilitation challenges considering likely occult and subtle cognitive changes in covid-19 survivors 39. Reduced access to essential rehabilitation services exacerbates delirium and is likely to impede cognitive recovery after critical illness.…”