Eight months after falling ill with Covid-19, the 73-year-old woman could not remember what her husband had told her just hours earlier. She will forget to remove the laundry from the dryer at the end of the cycle. He would turn on the faucet to a basin and leave.
Before Covid, the woman was doing bookkeeping for a local business. Now, he couldn’t add up single digit numbers in his head.
Was it the early stages of dementia, unmasked by covid? no When a therapist assessed the woman’s cognition, her scores were normal.
What was going to happen? Like many people infected with Covid, this woman had difficulty sustaining attention, organizing activities and multitasking. He complained of brain fog. He didn’t feel like himself.
But this patient is lucky. Jill Jonas, an occupational therapist affiliated with Washington University School of Medicine in St. Louis who described her to me, is providing cognitive rehabilitation to the patient and he’s getting better.
Cognitive rehabilitation is therapy for people whose brains have been damaged by trauma, traumatic accidents, strokes, or neurodegenerative conditions such as Parkinson’s disease. It is a suite of interventions designed to help people recover from brain injury, if possible, and adapt to ongoing cognitive impairment. Services are typically provided by speech and occupational therapists, neuropsychologists, and neurorehabilitation specialists.
In a recent development, some medical centers are offering cognitive rehabilitation for patients with prolonged covid (symptoms that persist for months or more after 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 enthusiastic about the potential of cognitive rehabilitation. “Imaginatively, we are seeing a lot of people [with long covid] make significant gains with the right type of intervention,” says Monique Tremaine, director of neuropsychology and cognitive rehabilitation at the JFK Johnson Rehabilitation Institute at Meridian Health in Hackensack, New Jersey.
Post-Covid cognitive complaints include 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 have this type of problem. Meanwhile, a new review in Nature Medicine found that hospitalized Covid survivors had 37% more brain fog than comparable peers who had no known Covid infection.
In addition, there is emerging evidence that older adults are more likely to experience post-Covid cognitive challenges than younger adults—a vulnerability attributed, in part, to older adults’ predilection for other medical conditions. Cognitive challenges arise from small blood clots, chronic inflammation, abnormal immune responses, brain injuries such as strokes and hemorrhages, viral persistence, and neurodegeneration caused by Covid.
Getting help begins with an evaluation by a rehabilitation professional to identify cognitive functions that need attention and determine the severity of a person’s difficulties. One person may need help finding words when speaking, for example, another may need help planning, and another may not process information efficiently. There may be several deficits at the same time.
Next comes an attempt to understand how patients’ cognitive problems affect their daily lives. According to Jason Smith, a rehabilitation psychologist at the University of Texas Southwestern Medical Center in Dallas, among the questions therapists ask: “Is it [deficit] Showing up at work? At home? Somewhere else? What activities are being affected? What is most important to you and what do you want to work on?”
To try to restore damaged brain circuits, patients may be prescribed a series of repetitive exercises. If attention is a problem, for example, a therapist might tap a finger on 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 one can easily lose focus,” says Joe Giaccino, 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: for example, repeat the tapping action while answering questions about their personal background. “Now the brain has to divide attention—a much more demanding task—and you’re making connections where they can be made,” Giacchino continued.
A therapist will work with patients on practical strategies to deal with disabilities that interfere with people’s daily lives. Examples include making lists, setting alarms or reminders, breaking tasks down into steps, balancing activity with rest, figuring out how to conserve energy, and how 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,” says Alyssa Langi, a research assistant professor who studies cognitive rehabilitation at the University of Delaware.
Along the way, patients and therapists discuss what worked well and what didn’t, and practice useful skills, such as using calendars or notebooks as memory aids.
“When patients become more aware of where and why problems occur, they can prepare for them and they start to see improvement,” says Liana Cardanova Frantz, a speech therapist at Johns Hopkins University. “Many of my patients say, ‘I had no idea [kind of therapy] Can be so helpful.'”
Johns Hopkins is conducting neuropsychiatric testing of patients who come to its post-Covid clinic. About 67% suffer from 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 meet with therapists once or twice a week for two to three months.
Before trying this type of therapy, other problems may need to be addressed. “We want to make sure people are getting enough sleep, maintaining their nutrition and hydration, and exercising to maintain blood flow and oxygenation to the brain,” Frantz said. “They affect our cognitive function and communication.”
Depression and anxiety—common companions to those who are seriously ill or disabled—also require attention. “A lot of times when people are struggling to manage deficits, they’re focusing on what they were able to do in the past and really mourning the loss of performance,” Tremaine said. “There’s a big psychological component that needs to be managed.”
Medicare generally covers cognitive rehabilitation (patients may be required to pay a co-payment), but Medicare Advantage plans can vary in the type and length of therapy and how much they’ll reimburse providers — an issue that can affect access to care.
Still, Tremaine points out, “many people don’t know about cognitive rehabilitation or understand what it does, and it remains underserved.” He and other experts don’t recommend digital brain-training programs marketed to consumers as an alternative to practitioner-led cognitive rehabilitation because of the lack of personal assessment, feedback and coaching.
Also, experts warn, while cognitive rehabilitation can help people with mild cognitive impairment, it is not appropriate for people with advanced dementia.
If you notice cognitive changes of concern, ask your primary care physician for a referral to an occupational or speech therapist, says Erin Foster, an associate professor of occupational therapy, neurology and psychiatry at Washington University School of Medicine in St. Petersburg. Louie. Be sure to ask therapists if they have experience solving memory and thinking problems in everyday life, she recommends.
“If there is a medical center in your area with a rehabilitation department, contact them and ask for a referral for cognitive rehabilitation,” says Smith of UT Southwestern Medical Center. “The professional discipline that is most helpful in cognitive rehabilitation is rehabilitation medicine.”
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