How to help patients with cognitive symptoms of long COVID

While there is some evidence that COVID-19 could cause structural changes in the brain, the generalized cognitive symptoms seen in patients with long COVID are usually not indicative of serious cognitive decline, experts say. People experiencing long COVID—also called post-COVID syndrome—report cognitive symptoms that include brain fog and problems with concentration and memory. “Those are the most common symptoms with long COVID related to cognition, but they’re also, honestly, the most common symptoms of pretty much anyone with any health conditions of any kind,” said Dr. Lesley Fellows, a neurologist and professor at McGill University. They’re the symptoms of the brain not working properly. “Family doctors will be accustomed to seeing that kind of pattern,” she said. Sussing things out It's important to reassure patients that the pattern of symptoms reported in long COVID is usually distinct from what is seen in people with progression of a primary major memory disorder. Physicians should check for other conditions which may contribute to poor cognitive function, Dr. Fellows said. Check for proper blood glucose control, thyroid dysfunction, vitamin B12 deficiency, metabolic problems or adverse effects from medications. Also consider other consequences of COVID illness, such as mental health challenges fatigue, or if the patients were very sick from the virus. “Try to do a 360 in terms of clarifying what else may be going on, some of which may be more directly treatable,” Dr. Fellows advised. Read: Doctors suggest new names for low grade prostate cancer While there are some resources to guide investigations, the main tools in investigating long COVID should be the same as any condition: a careful medical history and physical, said Dr. Wendy Levinson, chair of Choosing Wisely Canada. Further medical tests can then be done in a targeted way to rule out other diagnoses. Currently, there are no Choosing Wisely recommendations as to what tests to pursue, and what tests to avoid, in order to diagnose long COVID. “This is too new to accumulate enough information for societies to make recommendations through us,” Dr. Levinson said. “We’re in a learning phase on this topic. Maybe things will be clearer in a year." Taking action There may be several actionable areas for treating long COVID cognitive symptoms, Dr. Fellows said. “Because it is a non-specific sign that the brain is not in shape, anything that you can do to improve the brain’s health will improve function,” she said. This includes establishing and keeping a routine, taking steps to reduce distractions, following proper sleep hygiene, getting exercise, addressing stress and other mental health problems, tackling tasks one at a time, and taking regular breaks. “Executive function and attention are really called upon if you’re trying to deal with many things at once under a time pressure that are not routine,” Dr. Fellows said. “That might be an experience people are having if they’re working from home; they’re trying to accomplish tasks that they didn’t do before COVID and that takes pressure on anyone’s brain.” “I think people are asking a lot of themselves. Even if their brains are in perfect health, I think many people are feeling overwhelmed,” she said. Read: Health Canada issues treatment failure warning for COVID-19 monoclonal antibody therapy Neurological symptoms of long COVID also include paresthesia, headache, dizziness and insomnia. Persistent headaches could have other causes, such as hypertension, autoimmune conditions or tension headaches. Patients with long COVID headaches respond well to existing treatments for headaches and migraines, Dr. Angela Cheung told CBC News. Dr. Cheung is an investigator in two long COVID clinical trials and a senior scientist at the Toronto General Hospital Research Institute. Dr. Fellows thinks many of the long COVID cognitive symptoms can be managed in the primary care setting. “I think it is likely that a lot of this is well within the comfort zone of a typical primary care physician, in the sense that it is not so different in the kinds of symptoms people have with other substantial health issues and the same advice is likely to be helpful for much of the problems people are facing,” Dr. Fellows said. “The fact that this is heterogeneous, the fact that there are multiple potential contributors is aligned with how primary care physicians typically look at the world’” she said. Dr. Fellows and colleagues will be launching a website for people with long COVID cognitive symptoms that will provide patients with tools to manage their symptoms. It is called Quebec Action Post-COVID and will also collect data for research. More information will be available in the coming months. Why people are having cognitive and neurological symptoms is not yet understood. It is not known whether they’re caused by the infection itself, or are a result of the acute infection, or due to other factors that arise over time. There are probably some subtle changes in the brain, “but what exactly that means isn’t clear,” Dr. Fellows said. Dr. Fellows cited research by Dr. Gwenaëlle Douaud and colleagues at Oxford University, that showed patients with moderate to mild cases of COVID-19 had structural changes in the brain detected on MRI scans performed an average of 141 days following COVID-19 diagnosis. The changes following COVID infection were mostly in brain areas associates with smell. The patients who were infected with SARS-CoV-2 showed more cognitive decline than patients who did not have COVID-19. “It’s probably the best evidence we have around brain changes with COVID,” Dr. Fellows said. Further research is needed to determine if the structural changes in the brain persist over time. The findings were published in Nature in March 2022. Read: What do sole overnight ER docs do all night?

How to help patients with cognitive symptoms of long COVID

Register for free access or login.

Related Topics