Ask the Experts: The impact of COVID brain fog on COVID-19 survivors
Akili is collaborating with Weill Cornell Medicine, NewYork-Presbyterian Hospital and Vanderbilt University Medical Center to study the potential of a digital therapeutic to treat brain fog in COVID-19 survivors.
Akili Chief Medical Officer Anil Jina, M.D., reflects on the importance of the research
In advance of the clinical studies, Akili Chief Medical Officer Anil Jina, M.D., discussed the issue of COVID brain fog with Faith Gunning, Ph.D., Vice Chair of Research and Psychology in the Department of Psychiatry at Weill Cornell Medicine and associate attending psychologist at NewYork-Presbyterian/Weill Cornell Medical Center, Abhishek Jaywant, Ph.D., Assistant Professor of Neuropsychology in Psychiatry at Weill Cornell Medicine and assistant attending psychologist at NewYork-Presbyterian/Weill Cornell Medical Center, and James Jackson, PsyD, Assistant Director of The ICU Recovery Center at Vanderbilt and lead psychologist for The Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center at the Vanderbilt University Medical Center.
The following conversation explores their current understanding and impact of COVID brain fog on COVID-19 survivors. It has been edited and condensed for clarity.
Q. We’re launching studies with your organizations to see if Akili’s digital therapeutic might be effective in treating COVID brain fog. Can you talk a bit about why you're excited to research this condition?
Dr. Faith Gunning: I don't use the word lightly, but our country, communities and many patients have experienced what I perceive as a collective trauma, and I think many of us who work within the medical community are so motivated to help our communities recover. There’s such a great need for our patients and there are going to be so many patients coming who need help. I think there's a more personal connection to this study than with most research questions because I know from my own experience the devastation our medical community felt, especially early on, and have seen how my colleagues rose to the occasion to meet this challenge. I think we feel really devoted to taking care of the patients.
Dr. James Jackson: For me it feels deeply personal [for the reasons Faith alluded to]. It also feels like a very strategic place to work, by which I mean these patients and their families are in great distress and if there's a lever we can pull to alleviate that, we want to do it. If that lever is rehabilitation of cognition and improving attention and processing speed, we've improved a lot for people – we've improved their quality life, we've likely improved their marriages, their ability to engage in work or graduate from college. All those things are improved because we've improved their mental health by improving their cognition. That’s what’s really exciting to me.
Dr. Abhishek Jaywant: Being in the inpatient setting and working with survivors starting last April, there is a special bond that is hard to capture in words. There are many patients I still think about and never forget. I mean it was different from usual rehab, both because of what we were going through as a city and ultimately as a society and country, but these patients were in rehab for sometimes 30 to 40 days or more. Meeting with them multiple times a week, you develop a relationship. If we can make even a small dent and hopefully, even a bigger impact, it would be incredibly rewarding. This is a group of people who have been through a lot but have a lot of resilience and courage and bravery, and to be able to see that and be part of it in a way is tremendously meaningful.
Q. There’s still so much we don’t know about COVID brain fog. How would you define it today?
FG: As the pandemic has progressed, “brain fog” became an umbrella term for the sense that an individual’s thinking is not quite the way it used to be prior to their illness. “COVID brain fog” specifically refers to long-term neurological and cognitive symptoms in patients who have recovered or are recovering from COVID-19. Generally, these patients report feeling mentally off, have difficulty with tasks that used to be easy for them, and experience a mental fogginess.
Q. When you talk to patients experiencing COVID brain fog, how is it impacting their lives?
JJ: I’ve talked to patients where the impact of COVID brain fog on employment really emerged. Specifically, having issues in what I would call attentional and processing speed related arenas, so having problems at work concentrating, making careless errors they hadn't made before, highly distractible. These are some of the most common complaints we hear, in addition to doing everything much more slowly. The phrase we often use with patients is “twice as hard for half as much.” There’s no problem with effort and yet the return is greatly diminished despite the increased effort. For many patients, their symptoms jumpstart anxiety that maybe they didn't have before and then that anxiety feeds the concentration problems and the focus problems. It becomes a bit of a vicious cycle.
AJ: Jim, it’s so interesting to hear you say that. From Weill Cornell Medicine’s data these are exactly the kind of things we saw in our objective neuropsychological measures as well. It was attention, processing speed, multitasking, holding a lot of information in mind at once, and working memory. The inpatient setting is very structured, but these are exactly the symptoms I worried would be the daily life manifestations, and a lot of the people we treated are young enough to still be working or have families they're supporting.
JJ: It really is concerning. For some patients, they leave rehab and are in a bit of an extended convalescence before they transition back. Some of them lack awareness of the magnitude of their difficulties until you drop them in the deep end of the pool, and they realize “Oh my gosh my arms aren't working. I can't swim anymore,” so to speak. That's when it hits them in the face.
In some cases, I think they should have waited to return to work or school, but because they are not aware necessarily of the full weight of their deficits, they're in over their heads. If the current numbers hold, it’s quite a huge public health problem when you look at the notion that there would be literally millions of people impacted. It's really shocking to think of the impact.
FG: Jim, if I had to say what keeps me up at night right now, that's what it is. Even if most people experience full recovery, even if it's a relatively small subset based on the number of people who have had the illness, the public health significance is tremendous. It’s concerning to think about the number of people who may end up with a disability from COVID-19 and how we're going to manage supporting these individuals from a cognitive rehabilitation standpoint going forward so they can function in their daily lives.
Q. We’re still learning about COVID brain fog, but can you explain what research has revealed to date on how many people are affected?
AJ: We recently completed one of the largest COVID-19 studies on cognitive functioning, where we looked at 57 patients who were treated in the inpatient rehabilitation units at NewYork-Presbyterian/Weill Cornell Medical Center. These 57 patients represent a subset of the survivors. Most of them were ventilated for long periods of time and all of them had significant changes to their physical functioning that required rehabilitation before going home.1
We found 81% of our sample of patients had cognitive deficits. Most of them were mild, approximately a quarter had more moderate cognitive deficits and then a handful were more severe. While this was among the largest studies conducted so far, our number of patients was still fairly small, so I think it's still too early to know the true prevalence at a population level or broader level. Interestingly, there are some additional studies that show rates of cognitive impairment in hospitalized COVID-19 patients close to our finding of 81%. So it is a subset, and the rates may be different in patients who were never hospitalized, but that’s kind of where we're at right now.
Q. What are some of the prevailing theories on what's causing COVID brain fog?
JJ: I think it depends a bit on what the experience has been of each COVID-19 patient. If they have been critically ill in the ICU, as many of them have been, there could be a range of causes for those patients. For example, they've had extended time on mechanical ventilations, so they could have potentially had hypoxic brain injuries. They've had sepsis, they could have issues associated with consequences of inflammation.
Where it's harder to parse out is among the COVID-19 long haulers who have not been critically ill. They haven’t been on a ventilator. Some of them have never even been into the hospital, and some of them, while they report being largely asymptomatic, still report significant and enduring cognitive problems. We're still not exactly sure what's driving their impairment.
Q. How are we treating these patients today? What are their options?
AJ: Now that we’ve conducted studies and are seeing cognitive weakness associated with COVID-19, we’re looking to tap interventions we know have fairly good data on other populations and adapting those treatments for COVID-related cognitive deficits. This includes looking at digital therapeutics. We’re looking at how those treatments can be applied to COVID-19 patients experiencing cognitive deficits.
FG: We have a clinic set up for COVID-19 survivors in which we focus on their mental health, because we have treatments that help with depression and anxiety. To get to the larger population, we must use interventions that can be widely disseminated and target attention and executive deficits, as well as processing speed deficits. If we rely on traditional in-person one-on-one treatment, only a small subset of people experiencing COVID brain fog will get treated. Getting the intervention for COVID brain fog into people's homes is key, because otherwise we're going to have a tremendous bias in who ends up getting treated and it may not be the people who need it the most.
JJ: Scalability is such a critical aspect of treating COVID brain fog. There are many people who need services who never find their way to us, so I think taking a resource to the masses is really important.
Q. Do you think COVID-19 might help address the stigma around mental health? Will this be the point where cognitive health starts being thought of as a critical piece of a person’s holistic health?
FG: I have worked in rehab medicine since I was in graduate school over 20 years ago. In the past we didn't have good cognitive interventions. Now that there are cognitive interventions out there that can be widely disseminated, it's a great opportunity to draw attention to cognitive concerns that are present across many illnesses. The wonderful thing is that we can now do something to treat them, because 10 years ago, we didn’t have a treatment like a digital therapeutic to offer patients.
AJ: It’s also an opportunity to educate providers. I'm reminded of when I lecture to our rehab medicine residents about stroke recovery. I always explain the neuropsychological challenges experienced by stroke survivors. If you look at stroke patients’ post-rehab functional outcomes, it's often cognition, anxiety and depression that predicts how well they do, not their physical fitness. For the provider there needs to be a kind of acknowledgement that these are very real, if unseen, effects. So often people focus on the limb that's not working because that's very apparent to people, but cognition is really important, and we have the tools to help people struggling with it.
JJ: As you said, not only can cognitive functioning predict outcomes, but I think it's also true that in the hierarchy of things that patients’ value, cognition is at the top of the pyramid. I was speaking with someone about loss of smell and taste, and I made the point that it was a problem, but if you rank what survivors say about smell and taste relative to a brain injury, it doesn’t rank very high. In my experience, loss of taste and smell is number 20 or 30 on the list compared with being so tired I can’t walk across the room, or I can’t balance my checkbook, or can’t remember names. Those are the concerns people identify and therefore the concerns I think we should prioritize. We owe that to patients.
For more information on COVID brain fog, please visit [link].
¹Jaywant et al. Frequency and profile of objective cognitive deficits in hospitalized patients recovering from COVID-19. Neuropsychopharmacol. (2021).