The emergence of COVID-19 has stimulated extensive research into its epidemiology and pathogenesis as well as the development of new strategies to prevent and treat this novel condition. This article in its first section will discuss the current status of the pandemic and evolving diagnostic and therapeutic advances, focusing particularly on the neurological and psychological aspects of this illness. The second section of the article will describe a comprehensive program for the evaluation and management of the myriad neuropsychological aspects of COVID-19.
A Physician’s Perspective
The coronavirus disease 2019 (COVID-19) pandemic, due to the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has caused a worldwide sudden and substantial increase in hospitalizations for pneumonia with multi-organ disease.
SARS-CoV-2 is spread primarily via respiratory droplets and/or aerosols during face-to-face contact as well as hand-to-face spread following hand contact with infected surfaces. Infection can be spread by asymptomatic, pre-symptomatic and symptomatic carriers. The average time from exposure to symptom onset is 5 days, and 97.5% of people who develop symptoms do so within 11.5 days. The most common symptoms are:
- Fever or chills
- Shortness of breath or difficulty breathing
- Muscle or body aches
- New loss of taste or smell
- Sore throat
- Congestion or runny nose
- Nausea or vomiting
Diagnosis is made by detection of SARS-CoV-2 via reverse transcription polymerase chain reaction (PCR) testing. Although false-negative test results may occur in up to 20% to 67% of patients, this is dependent on the quality and timing of testing. This type of testing identifies current viral infection. Testing for antibodies, known as serological or blood testing, identifies previous infection. Manifestations of COVID-19 range from asymptomatic carriers to fulminant disease characterized by sepsis and acute respiratory failure. Approximately 5% of patients with COVID-19, and 20% of those hospitalized, experience severe symptoms that necessitate intensive care. More than 75% of patients hospitalized with COVID-19 require supplemental oxygen. Treatment for individuals with COVID-19 includes best practices for supportive management of acute hypoxic respiratory failure. Emerging data indicate that dexamethasone therapy reduces mortality in patients requiring supplemental oxygen compared with usual care, and that Remdesivir improves time to recovery. Dexamethasone is a potent corticosteroid thought to dampen the acute inflammatory response that complicates COVID-19, a phenomenon known as “cytokine storm.” Remdesivir is an antiviral agent that reduces the replication rate of the virus. At this point, only Remdesivir and dexamethasone are approved for therapy of severe illness.
Ongoing trials are in progress to evaluate additional antiviral therapies, anticoagulants, immune modulators, monoclonal antibodies, hyperimmune globulin and the use of convalescent plasma. Multiple vaccines are moving forward with Phase 3 trials. Some of these are expected to be concluded by late fall.
The case-fatality rate for COVID-19 varies markedly by age, ranging from 0.3 deaths per 1000 cases among patients aged 5 to 17 years to 304.9 deaths per 1000 cases among patients aged 85 years or older in the US. Among patients hospitalized in the intensive care unit, the case fatality has been as high as 40%. Much has been learned about optimal management of COVID-19 in the ICU, and the use of positioning and ventilators, along with the drugs above, have yielded improved mortality outcomes.
It has been well-established that certain demographic and comorbid conditions predispose individuals to suffer severe COVID-19 illness. A recent study has identified that adult age, and any one of chronic obstructive pulmonary disease, heart disease, diabetes, obesity and chronic kidney disease, are highly prevalent in many U.S. counties, with a median of 47.2 % of the population at excess risk.
There are 4 million recorded positive cases in the U.S. and 10 million worldwide. But most experts believe this significantly understates the actual count by excluding those who are asymptomatic and/or have never been tested. A just-published study measuring the seroprevalence of antibodies (positive results) at 10 sites in the U.S. revealed that from 6 to 24 times more people have been exposed to the virus than the number of reported cases. This would suggest that the case count is at a minimum of 24 million and higher.
While this is troubling, it still is well short of infection levels needed to reach the level of acquired or “herd” immunity that will mitigate the transmission of the virus, which experts generally agree is 60-70 % of the population.
The count of COVID-19-related deaths in the U.S. is currently 151,000. This too, however, is likely understated. Based on “excess death” calculations (comparing deaths during COVID-19 period to the same timeframe last year) there are 28% more deaths, which would suggest that mortality is approximately 193,000.
We will now turn to the neurological and neuropsychiatric aspects of COVID-19. The literature has reported the following less severe but quite common symptoms: headache, dizziness, anosmia and ageusia (loss of smell and taste).
A case report analysis of more severe neuropsychiatric COVID-19 presentations in the U.K. grouped them into the following broad categories with their respective proportions:
- Cerebrovascular events 62%, inclusive of ischemic strokes, intracerebral hemorrhage and vasculitis
- Altered mental status 31%, inclusive of encephalitis, encephalopathy, neurocognitive disorders and psychosis
- Peripheral nervous system disorders 5%, inclusive of Guillain-Barre Syndrome (GBS) and others
- Other unspecified 2%
There is controversy as to the pathogenesis of these conditions. Some authorities feel that the virus, like other coronaviruses, is neuro-invasive, directly attacking central and peripheral nervous system structures. There is still a paucity, however, of compelling evidence for this pathway. Others feel that neurological and neuropsychiatric complications can arise from the numerous systemic disturbances that comprise COVID-19 illness. The primary culprit may be hypoxemia (diminished blood oxygen) as a consequence of respiratory impairment. Several toxic and metabolic disruptions occur in the course of the condition. A tendency towards hyper-coagulation (increased blood clotting) may promote strokes and other thromboembolic events in the brain and elsewhere. Diffuse inflammation and an energized autoimmune state may cause blood and nerve swelling (vasculitis and neuritis).
COVID-19 patients additionally have prolonged ICU stays, often on ventilators, and the consequent sensory deprivation, physical de-conditioning and the effects of many neuroactive medications used in that setting can result in an exaggerated form of the post-intensive care syndrome that occurs in many other illnesses after ICU stays.
While we hope that many of the complications described above will be reversible to a greater or lesser extent, we do face the potential challenge of chronic or permanent impairments that will require extensive treatment and rehabilitation. Sadly, many of them will likely result in disabilities and altered life expectancies.
We now turn to the psychological aspects of SARS-CoV-2. Widespread concern and anxiety have disrupted all our lives and, in particular, those who have been exposed to or contracted the illness and require additional assessment, support and therapy.
A Psychologist’s Perspective
For those recovering from COVID-19 illness and the even larger number of individuals whose lives have been significantly impacted indirectly by the pandemic, the key issues that can be addressed by mental health providers include the following:
- Informed and reasonable information about the virus and preventative measures, such as personal protective equipment (PPE), social distancing and hand-washing;
- Providing strategies to improve coping and stress tolerance, such as mindfulness and meditation exercises, sleep hygiene and ways to maintain social connections;
- Return-to-work readiness determinations from a mental health point of view with appropriate work-restrictions and accommodations based on an individual’s job demands and work environment conditions;
- Grief and loss counseling;
- Telemed-based, trauma-focused Cognitive Behavioral Therapy (CBT) or other evidence-based treatment approaches for treatment of COVID-19 related Post-Traumatic Stress Disorder (PTSD);
- Increased intensity of treatment, by frequency or duration of therapy sessions, for acute exacerbations of pre-existing mental health issues (e.g. depression, PTSD, social anxiety, agoraphobia, generalized anxiety, major depression, etc).
Mental health providers with specialized training in neuropsychology and behavioral medicine/health psychology will be especially helpful for those COVID-19 survivors who have had the more severe illnesses described in this section. It will be important for providers to be aware of breathing strategies to improve respiratory efficiency without increasing the risk of injuring vulnerable lung tissues. Reducing stress and improving hopefulness, resiliency, sleep and social support are all key strategies that behavioral health practitioners are familiar with. Assessing the neurocognitive impact of illnesses is also an important skill domain that most psychologists are uniquely able to contribute.
Recent advances in computer-administered neurocognitive testing have allowed psychologists and neuropsychologists to be able to administer psychological and neurocognitive assessment instruments by telemedicine. The publishers of many psychological tests have adapted their administration for co-monitoring by examiners, and there are now many more neurocognitive assessment batteries available to aid in the detection and quantification of neuropsychological functioning deficits. Mental health providers have been adapting the MMPI-2-RF®, SCL-90-R® and the CNS Vital Signs® in workers’ compensation assessment of neurocognitive features of concussion and post-concussion syndrome, using telemed for assessment of post-COVID-19 neurocognitive features.
For survivors who have had prolonged periods of dyspnea (shortness of breath), hypoxemia (decreased blood oxygen levels) and hypoxia (decreased oxygenation of organs), neurocognitive screening and ongoing monitoring of mental status will be helpful. In addition, individuals should be prepared to monitor their own blood O2 saturation levels using a pulse oximeter if they are having continued symptoms of hypoxemia and hypoxia (dizziness, headache, muscle fatigue, dyspnea and decreased concentration). Periodic neurocognitive screening may also be useful, such as the CNS-VS®, ImPACT®, MOCA® or other tools. This may be especially important for those with COVID-19 issues since it is associated with silent hypoxia, which can result in more neurocognitive symptoms with fewer overt signs of respiratory distress.
A key issue will be encouraging the use of alternative means of maintaining social contact and support to overcome isolation due to social distancing guidelines, such as through the use of phone and internet technology. It will be especially important for individuals recovering from COVID-19 illness to have alternative means of accessing social support. Those who have recovered from the illness may be especially vulnerable to distress, resulting from re-exposure prior to or after returning to work. This is especially likely for healthcare workers who may be in early recovery from COVID-19 and yet are required to work with infected patients. Use of a peer or buddy system for monitoring exposure risk, as well as to alleviate anxiety and stress, will be key for sustained return-to-work success for many workers at risk of re-exposure.
For many providers, this may be the first time they are working with individuals who are not presenting with anxiety, but with fear. Anxiety is a state of worry or anticipated negative outcomes, dread or pre-occupation that is not rational or is exaggerated or excessive. Fear is the emotional reaction to an actual threat to one’s own or other’s health or safety. Although many of us work with clients who face actual danger in their jobs (e.g. active duty military, first responders and those in hazardous occupations, like mining, forestry or construction industries), most people do not typically face life-threatening conditions at work.
This has completely changed with COVID-19 for the first time in our lifetimes. This is the first time in recent history that all of humanity has faced a common threat. As such, for as much as it poses a threat, it also provides an opportunity. That opportunity is to find common ground through mutual effort, to ignore social, cultural and national differences, and focus on the unifying experience of overcoming this crisis.
Dr. Lazarovic, M.D., F.A.A.F.P., has nearly 40 years of medical administration/managed care experience, including 18 years as Chief Medical Officer at Broadspire/CRAWFORD, a global third-party administrator of workers’ compensation, disability, auto and medical product liability claims. Experienced in clinical guidelines, medical cost control and strategic planning, Dr. Lazarovic has conducted and published original research and analytics and presented at multiple industry conferences. Dr. Lazarovic is currently the CMO responsible for the development of advanced, evidence-based clinical applications at MyAbilities Technologies, a medical software and services company in the workers’ compensation and disability sector.
Dr. LeGoff, Ph.D., LP, is a licensed neuropsychologist with more than 25 years of clinical experience, having held many prestigious clinical and teaching positions at Ivy League universities and government and healthcare institutions nationwide. Dr. LeGoff’s broad clinical expertise encompasses psycho-educational, neuropsychological, and psycho-diagnostic evaluation and treatment. Dr. LeGoff was embedded as a neuropsychologist at a rehabilitation program at a large workers’ compensation organization. A world-renowned speaker, author and expert in personal development and cognitive behavioral therapy, Dr. LeGoff has conducted professional training worldwide.
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