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Eight months after falling ill with covid-19, the 73-year-old woman couldn't remember what her husband had told her a few hours before. She would forget to remove laundry from the dryer at the end of the cycle. She would turn on the tap at a sink and walk away.
Before covid, the woman had been doing bookkeeping 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 assessed the woman's cognition, her scores were normal.
What was going on? Like many people who've contracted covid, this woman was having difficulty sustaining 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 the Washington University School of Medicine in St. Louis who described her to me, has been providing cognitive rehabilitation to the patient, and she is getting better.
Cognitive rehabilitation is therapy for people whose brains have been injured by concussions, traumatic accidents, strokes, or neurodegenerative conditions such as Parkinson's disease. It's a suite 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 covid (symptoms that persist several months or longer after an infection that can't 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 cognitive rehabilitation's potential. "Anecdotally, we're seeing a good number of people [with long covid] make significant gains 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 visual-spatial orientation. A recent review in JAMA Psychiatry found that up to 47% of patients hospitalized in intensive care with covid developed problems of this sort. Meanwhile, a new review in Nature Medicine found that brain fog was 37% more likely in nonhospitalized covid survivors than in comparable peers who had no known covid infections.
Also, there's emerging evidence that seniors are more likely to experience cognitive challenges post-covid than younger people — a vulnerability attributed, in part, to older adults' propensity to have other medical conditions. Cognitive challenges arise because of small blood clots, chronic inflammation, abnormal immune responses, brain injuries such as strokes and hemorrhages, viral persistence, and neurodegeneration triggered by covid.
Getting help starts with an assessment by a rehabilitation professional to pinpoint cognitive tasks that need attention and determine the severity of a person's difficulties. One person may need help finding words while speaking, for instance, while another may need help with planning and yet 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 issues affect their daily lives. Among the questions that therapists will ask, according to Jason Smith, a rehabilitation psychologist at the University of Texas Southwestern Medical Center in Dallas: "Is this [deficit] showing up at work? At home? Somewhere else? Which activities are being affected? What's most important to 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 attention is the issue, for instance, a therapist might tap a finger on the table once or twice and ask a patient to do the same, repeating it multiple times. This type of intervention is known as restorative cognitive rehabilitation.
"It isn't easy because it's so monotonous and someone can easily lose attentional focus," said Joe Giacino, a professor of physical medicine and rehabilitation at Harvard Medical School. "But it's a kind of muscle building for the brain."
A therapist might then ask the patient to do two things at once: repeat the tapping task while answering questions about their personal background, for instance. "Now the brain has to split attention — a much more demanding task — and you're building connections where they can be built," 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 down tasks into steps, balancing activity with rest, figuring out how to conserve energy, and learning 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 that it does, in fact, enhance their everyday life," 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 well and what didn't, and practice useful 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 they start seeing improvement," said Lyana Kardanova Frantz, a speech therapist at Johns Hopkins University. "A lot of my patients say, 'I had no idea this [kind of therapy] could be so helpful.'"
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, said Dr. Alba Miranda Azola, co-director of Johns Hopkins' Post-Acute COVID-19 Team. When cognitive rehabilitation is recommended, patients usually meet with therapists once or twice a week for two to three months.
Before this kind of therapy can be tried, other problems may need to be addressed. "We want to make sure that people are sleeping enough, maintaining their nutrition and hydration, and getting physical exercise that maintains blood flow and oxygenation to the brain," Frantz said. "All of those impact our cognitive function and communication."
Depression and anxiety — common companions for people who are seriously ill or disabled — also need 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 that loss of efficiency," Tremaine said. "There's a large psychological component as well that needs to be managed."
Medicare usually covers cognitive rehabilitation (patients may need to contribute a copayment), but Medicare Advantage plans may differ in the type and length of therapy they'll approve and how much they'll reimburse providers — an issue that can affect access to care.
Still, Tremaine noted, "not a lot of people know about cognitive rehabilitation or understand what it does, and it remains underutilized." She and other experts don't recommend digital brain-training programs marketed to consumers as a substitute for practitioner-led cognitive rehabilitation because of the lack of individualized assessment, feedback, and coaching.
Also, experts warn, while cognitive rehabilitation can help people with mild cognitive impairment, it's not appropriate for people who have advanced dementia.
If you're noticing cognitive changes of concern, 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. Be sure to ask therapists if they have experience addressing memory and thinking issues in daily life, she recommended.
"If there's a medical center in your area with a rehabilitation department, get in touch with them and ask for a referral to 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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