Eight months after falling ill with COVID-19, a 73-year-old woman couldn’t remember what her husband had told her a few hours before. She forgot to remove laundry from the dryer at the end of the cycle. She turned on the tap at a sink and walked away.
Before COVID-19, the woman had been doing bookkeeping for a local business. Now she couldn’t add single-digit numbers in her head.
Was it the earliest stage of dementia, unmasked by COVID-19? No. When a therapist assessed the woman’s cognition, her scores were normal.
What was going on? Like many people who have contracted COVID-19, this woman was having difficulty sustaining attention, organizing activities, and multitasking. She complained of brain fog. She didn’t feel like herself.
Cognitive rehabilitation is therapy for people whose brains have been injured by concussions, traumatic accidents, strokes, or neurodegenerative conditions such as Parkinson’s disease. It’s a suite of interventions designed to help people recover from brain injuries, if possible, and adapt to ongoing cognitive impairment. Services are typically provided by speech and occupational therapists, neuropsychologists, and neurorehabilitation experts.
Experts are enthusiastic about cognitive rehabilitation’s potential.
“Anecdotally, we’re seeing a good number of people [with long COVID] make significant gains with the right kinds of interventions,” said Monique Tremaine, director of neuropsychology and cognitive rehabilitation at Hackensack Meridian Health’s JFK Johnson Rehabilitation Institute in New Jersey.
Also, there’s emerging evidence that seniors are more likely to experience cognitive challenges post-COVID than younger people—a vulnerability attributed, in part, to older adults’ propensity to have other medical conditions. Cognitive challenges arise because of small blood clots, chronic inflammation, abnormal immune responses, brain injuries such as strokes and hemorrhages, viral persistence, and neurodegeneration triggered by COVID-19.
Getting help starts with an assessment by a rehabilitation professional to pinpoint cognitive tasks that need attention and determine the severity of a person’s difficulties. One person may need help finding words while speaking, while another may need help with planning, and yet another may not be processing information efficiently. Several deficits may be present at the same time.
To try to restore brain circuits that have been damaged, patients may be prescribed a series of repetitive exercises. If attention is the issue, a therapist might tap a finger on the table once or twice and ask a patient to do the same, repeating it multiple times. This type of intervention is known as restorative cognitive rehabilitation.
A therapist might then ask the patient to do two things at once, such as to repeat the tapping task while answering questions about their personal background.
“Now the brain has to split attention—a much more demanding task—and you’re building connections where they can be built,” Giacino said.
To address impairments that interfere with people’s daily lives, a therapist will work on practical strategies with patients. Examples include making lists, setting alarms or reminders, breaking down tasks into steps, balancing activity with rest, figuring out how to conserve energy, and learning how to slow down and assess what needs to be done before taking action.
Along the way, patients and therapists discuss what worked well and what didn’t and practice useful skills, such as using calendars or notebooks as memory aids.
“As patients become more aware of where difficulties occur and why, they can prepare for them, and they start seeing improvement,” said Lyana Kardanova Frantz, a speech therapist at Johns Hopkins University. “A lot of my patients say, ‘I had no idea this [kind of therapy] could be so helpful.’”
Before this kind of therapy can be tried, other problems may need to be addressed.
“We want to make sure that people are sleeping enough, maintaining their nutrition and hydration, and getting physical exercise that maintains blood flow and oxygenation to the brain,” Frantz said. “All of those impact our cognitive function and communication.”
Depression and anxiety—common companions for people who are seriously ill or disabled—also need attention.
“A lot of times when people are struggling to manage deficits, they’re focusing on what they were able to do in the past and really mourning that loss of efficiency,” Tremaine said. “There’s a large psychological component as well that needs to be managed.”
Medicare usually covers cognitive rehabilitation (patients may need to contribute a copayment), but Medicare Advantage plans may differ in the type and length of therapy they’ll approve and how much they’ll reimburse providers—an issue that can affect access to care.
Still, Tremaine noted that “not a lot of people know about cognitive rehabilitation or understand what it does, and it remains underutilized.” She and other experts don’t recommend digital brain-training programs marketed to consumers as a substitute for practitioner-led cognitive rehabilitation because of the lack of individualized assessment, feedback, and coaching.
Also, while cognitive rehabilitation can help people with mild cognitive impairment, it’s not appropriate for people who have advanced dementia, experts say.
If you’re noticing cognitive changes of concern, ask for a referral from your primary care physician to an occupational or speech therapist, said Erin Foster, an associate professor of occupational therapy, neurology, and psychiatry at Washington University School of Medicine in St. Louis. Be sure to ask therapists if they have experience addressing memory and thinking issues in daily life, she said.
“If there’s a medical center in your area with a rehabilitation department, get in touch with them and ask for a referral to cognitive rehabilitation,” Smith said. “The professional discipline that helps the most with cognitive rehabilitation is going to be rehabilitation medicine.”
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