Several studies have suggested a relationship between COVID-19 and short-term cognitive impairment—often referred to as brain fog—which can persist for months after a COVID-19 diagnosis. A recent study published in JAMA Network Open found a relatively high frequency of cognitive impairment several months after patients contracted COVID-19, including among the study’s younger cohort.
In Advance podcast Episode 1: “Rehabilitation of Critically Ill COVID-19 Survivors,” Gerard Francisco, MD, chair of the Department of Physical Medicine and Rehabilitation at McGovern Medical School at UTHealth Houston and chief medical officer of TIRR Memorial Hermann, draws similarities between the cognitive symptoms exhibited by patients suffering from post-acute COVID-19 syndrome (PACS) and patients recovering from brain injuries resulting from stroke or concussion. “We now know that many of the non-pulmonary, non-cardiac symptoms and problems that occur after COVID can be addressed by rehabilitation, because they're quite similar to what we are dealing with in people with neurological conditions,” says Dr. Francisco.
Dr. Francisco is one of the nation’s leading physicians in the field of brain injury, stroke rehabilitation and spasticity management. He is the Wulf Family Chair in the Department of Physical Medicine and Rehabilitation, clinical scientist at TIRR Memorial Hermann, ranked No. 2 among the country’s top rehabilitation hospitals in the U.S. News & World Report’s Best Hospital rankings for 2021-2022.
Here, Advance takes a deeper dive to uncover additional insights to enable physicians, including primary care and internal medicine physicians, to help their patients get appropriate support as quickly as possible. “There’s an opportunity to educate physicians and the lay public that people who survived COVID may have some manifestations of problems that can be helped,” says Dr. Francisco.
First Step: Recognizing the Problem
Dr. Francisco says diagnosing cognitive dysfunction in PACS patients is fairly simple. “A physician can ask the patient few basic screening questions, such as, ‘Are you having trouble with thinking, with memory? Are you having trouble concentrating?’ These questions are not dissimilar to questions you would ask a concussion suspect,” he says.
But patients might not attribute their symptoms to COVID-19. “Sometimes the cognitive issues are minimized,” he says. “Either the patient is not aware, or he or she minimizes it, saying, ‘Oh, I'll be okay. I just forgot something.’ This is especially true in situations where there is a change in memory. Unless it's so drastic, unless it’s limiting their function, they will typically not ask for help.”
In addition, he says, it's not clear if it's something that sets in later, or it's something that is just noticed later, because the patient’s priorities earlier on had more to do with their physical problems after COVID.
PACS Inhibiting Performance
As more and more people suffering the aftereffects of COVID-19 hear about available treatments, self-referrals to TIRR Memorial Hermann are increasing. “We’re seeing individuals with cognitive, emotional and psychological issues related to COVID-19, either as a result of or a reaction to the other problems, which are causing trouble with their performance at work or at school. And many still have physical issues, balance. It's not just weakness. We thought before it was weakness. Right now, it's balance, which is a big issue,” he says.
Highly Coordinated Care
Patients are treated by TIRR therapists and/or are referred to the TIRR Memorial Hermann Challenge Program, proven to help brain injury patients build the strength, skills and confidence to resume their daily activities.
“TIRR has a breadth of services that are highly coordinated,” says Dr. Francisco. “A therapist treating someone with physical problems of COVID-19 might notice that the patient is having problems sequencing a not-so-elaborate exercise, and they’ll suggest a cognitive screen. Conversely, during the course of a patient’s treatment for memory problems in the Challenge Program, a therapist might note some clumsiness in picking up objects. Because of that coordination and communication within the rehab system, we are able to identify problems early on and intervene early on as well.”
Preparing for the Future
Even while the rehabilitation specialists at TIRR Memorial Hermann are continuously learning and applying this new knowledge to treating PACS patients today, Dr. Francisco says they are simultaneously planning for the future. “By systematically collecting our observations right now, pulling the data and analyzing them either through a formal study or just the systematic observation, we will gain more experience. So that when a similar problem happens in the future, we will be better prepared. We will know what we're fighting.”