ALL IN THE HEAD
COVID-19 NEUROLOGICAL SEQUELAE YET TO COME AUTHOR John J . Wernert , MD , MHA
Ten months into dealing with
the global impact caused by COVID-19 , we know much more about its impact on the body . We know the virus causes massive activation of our immune systems , with multisystem reactions to this inflammatory condition . What is now being explored are the more insidious effects of COVID-19 on the brain and nervous system .
Mrs . Alice M .* – a 78-year-old Black female widow was referred to our Behavioral Medicine HUB by her APRN Primary Care practitioner due to ongoing decline in her mood , cognitive cloudiness and complete lack of motivation . Alice had been through a difficult 2020 , having contracted COVID-19 pneumonia in early February which resulted in a five day hospital stay . She did not require ventilator support and did not develop acute respiratory distress syndrome . However , her recovery has been slow , and she has gone from being a social , animated and independent individual requiring minimal family support , to now requiring a family or church member checking on her every couple of hours . Her confusion has worsened and she now sits in her chair and does little around the house and requires prompting to perform her own hygiene . She had no prior psychiatric history and her memory previously had been sharp with only mild age-appropriate cognitive impairment . Her APRN had tried her on Zoloft for three months without much benefit . The family is concerned that she now has dementia and are asking about Alzheimer ’ s medications . A recent head CT showed only age related changes and mild white matter changes . Her follow up COVID-19 tests are negative .
Many patients who experience COVID-19 exhibit neurological symptoms , from loss of smell , acute encephalitis , persistent post-infection confusion and an increased risk of stroke . There are longer-lasting consequences for the brain , including chronic fatigue syndrome and memory impairment . These effects may be caused by direct viral infection of brain tissue and / or blood vessels . But growing evidence suggests that the virus can cause ongoing impairment through the immune system , with inflammation contributing to lasting neurological changes after COVID-19 .
Cognition is how we acquire knowledge , make sense of stored information and use it to complete tasks . Impairment in cognition affects your ability to retain information and recall past experiences ( memory ), your ability to concentrate ( focus ) and your ability to respond to stimuli ( attention ). Because COVID-19 involves a massive release of inflammatory signals , the impact of this disease on memory is a particular concern . That is because there are both short-term effects on cognition and the potential for long-lasting changes in memory , attention and cognition . There is also an increased risk for cognitive decline and dementia , including Alzheimer ’ s disease , during aging .
The potential connection between COVID-19 and persistent effects on memory is based on observations of other illnesses . For example , many patients who recover from heart attack or bypass surgery report lasting cognitive deficits that become exaggerated during aging . Another major illness with similar cognitive complications is sepsis — multi-organ dysfunction triggered by inflammation . In animal models of these diseases , we also see impairments of memory and changes in neuroimmune and neuronal function that persist weeks and months after illness .
Prevention of infection is obviously the primary goal , but treatments must be developed that address both the physical and neurological impact of the virus . Several emerging treatments for COVID-19 are drugs that suppress excessive immune activation and inflammatory states . Potentially , these treatments also will reduce the impact of inflammation on the brain and decrease the impact on long-term brain health .
Mrs . Alice has continued to struggle , and our conservative treatment measures have resulted in minimal improvement . Sadly , she may soon require assisted living or extended care if she continues to decline .
COVID-19 will continue to impact health and well-being long after the pandemic is over . As such , it will be critical to continue to assess the vulnerability of its victims to later cognitive decline and dementias . It will be many years before we know whether the COVID-19 infection causes an increased risk for cognitive decline or Alzheimer ’ s disease . But this risk may be decreased or mitigated through prevention and treatment of COVID-19 .
* The patient ’ s name and other identifying information have been changed to protect their identity .
Dr . Wernert , MHA is the Executive Medical Director of Norton Medical Group and practices with Norton Behavioral Medicine .
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