Introduction

Long COVID, otherwise known as Post-Acute Sequelae of SARS-CoV-2 infection (PASC), is a condition that continues to mystify researchers and healthcare professionals around the world. It manifests with lingering symptoms or developing new ones weeks after the acute phase of the virus has passed. It is important to know that prolonged symptoms of the virus affect 65 million people worldwide. New data show that more than 40% of adults in the United States reported having COVID-19 in the past, and nearly one in five of those 18 to 64 years old are currently still having symptoms of “long COVID.” Among people age 65 and older, 1 in 4 has at least one medical condition that might be due to COVID-19. Roughly 25 million people in the U.S. and over 17 million people in Europe have long COVID symptoms, with many more in other parts of the world.
Long COVID can affect people of all ages, including those who initially had mild or asymptomatic cases of COVID-19. The severity and duration of long COVID symptoms can vary widely among individuals. Some people experience only mild and intermittent symptoms, while others might struggle with more severe and persistent issues that significantly impact their daily lives and ability to work or engage in usual activities.
Demographic global prevalence considers women more at risk than men, the elderly more than younger people, older children more than younger children, the Delta variant more than the Omicron; also smokers and lower income populations. Predisposing health conditions: obesity, asthma and COPD, depression and anxiety, those with unique symptoms and those hospitalized in the acute episode. A study using genotyping data found that people with a special HLA-B variant are 2 to 8 1/2 times more likely to be asymptomatic than those without the variant.

The exact cause of long COVID is still being researched, but hypothesis consider factors, including the virus persistence, the body’s immune response, post-viral inflammatory processes, blood clotting, lasting damage to organs and blood vessels and neurological dysfunction. Diagnosis is based on suspected or confirmed COVID-19 infection, symptoms and by excluding other causes.
A systematic review and meta-analysis presented more than 50 long-term effects of COVID-19, most common symptoms being fatigue (58%), headache (44%), attention disorder (27%), hair loss (25%), and dyspnea (24%).

Cognitive impairment can significantly impact a patient’s quality of life. This blog post will explore a case study of a patient of mine with Long COVID experiencing cognitive impairment and discuss the diagnostic criteria and management options for this condition.

Case Study

My patient, who I’ll refer to as “Mary,” is a 35-year-old who contracted COVID-19 and recovered partially from the acute phase of the illness. Mary’s cognitive symptoms persisted – daytime tiredness, brain fog, memory problems, and difficulty concentrating. These symptoms have significantly affected her ability to perform her job, and she is currently disabled.

Diagnostic Criteria

Currently, there is no universal diagnostic criteria for Long COVID. However, WHO and the National Institute for Health and Care Excellence (NICE) suggests that a diagnosis can be considered if the patient experiences symptoms that continue for more than 12 weeks and cannot be explained by another diagnosis. In Mary’s case, her cognitive impairment was evaluated and revealed deficits in memory, attention, and executive functioning. After 2.5 years of following up with more than 9.000 patients, the NIH RECOVER trial investigators of 200 clinical sites published in JAMA on May 25 2023 the largest study on long COVID to this date. They proposed a list of 12 symptoms that can be used to identify long COVID. The most common symptoms of long COVID they considered are:

• Post-exertional malaise (the worsening of symptoms following even minor physical or mental activity)
• Fatigue
• Brain fog
• Dizziness
• Gastrointestinal symptoms
• Heart palpitations
• Issues with sexual desire or capacity
• Loss of smell or taste
• Thirst
• Chronic cough
• Chest pain
• Abnormal movements

They identified 4 different types of Long COVID corresponding each one to probably different mechanism of action, which may result in different targets for treatments. Another study published this year showed that depression and anxiety levels are raised in the first two months after infection but return to normal values afterwards. This contrasted with other neuropsychological symptoms, such as brain fog and seizures, which lasted at least two years.

Management Options

The management of Long COVID with cognitive impairment is primarily symptomatic and rehabilitative. For Mary, we can include cognitive rehabilitation therapy to help her regain her cognitive abilities. This therapy involves strategies to improve memory, attention, and problem-solving skills. Antidepressants and anti-anxiety medication can also be considered. In addition, she would benefit from physical rehabilitation to improve her overall strength and stamina, which had been impacted due to prolonged illness. She was also provided with psychological support to cope with the anxiety and depression associated with the condition. She also began to implement lifestyle modifications, such as a balanced diet, regular exercise, and adequate sleep, which play a critical role in overall well-being and recovery.
Treatment and management strategies for long COVID are still evolving due to the relatively recent emergence of this condition. Healthcare professionals may focus on addressing specific symptoms, offering supportive care, and providing rehabilitation services such as physical therapy, occupational therapy, and mental health support.
On July 31, 2023 the NIH opened enrollment for phase 2 clinical trials that will evaluate at least four potential treatments for long COVID, with additional clinical trials to test at least seven more treatments expected in the coming months. They predict to conduct trials that have the potential to provide long COVID patients who experience varying symptoms with relief sooner than any individual study can alone.

Prognosis

The prognosis depends largely on the severity of clinical symptoms, underlying comorbid conditions, and response to treatment. One study analyzed patients at 6, 12, and 24 months after the disease onset. At the endpoint, more than half of them continued to report at least 3 symptoms – most frequently reporting fatigue, rheumatological and psychiatric symptoms, which highlights that the overall burden of the disease is high even 2 years after the acute episode.
As research continues, the medical community is working to better understand the underlying mechanisms of long COVID and to develop effective interventions to help those affected by this condition.

Conclusion

Long COVID with cognitive impairment is an emerging health condition that requires further research to better understand its pathophysiology and develop effective treatment strategies. In the meantime, a multidisciplinary approach involving cognitive rehabilitation, physical therapy, psychological support, and lifestyle modifications seems to be the most effective way to help patients like John manage their symptoms and improve their quality of life. As healthcare professionals, it’s crucial that we continue to learn, adapt, and provide our patients with the best possible care during these challenging times.
The case of Long COVID and cognitive impairment underscores the importance of long-term follow-up and comprehensive care for COVID-19 survivors. It is a reminder that the impact of this illness extends far beyond the acute phase, affecting individuals’ lives in profound and often unexpected ways. As more research efforts have been investigating this condition, we expect results to enlighten us more in terms of treatment and rehabilitation.