The Importance of Neuropsychology in the Early Rehabilitation of Patients with Critical Illness after Acute COVID Infection
Abstract
Abstract: The current literature has insufficiently examined the potential benefits of implementing early neuropsychological interventions for critically ill patients who have experienced COVID-19. To address this research gap, we conducted a descriptive analysis of clinical and neuropsychological data from N = 29 critically ill patients with COVID-19 admitted to an early neurological rehabilitation facility. Most patients had been diagnosed with critical illness polyneuropathy (CIP), and one-third exhibited additional brain damage. Upon admission, all patients exhibited severe cognitive impairments, demonstrating significant improvement following neuropsychological therapy. Nonetheless, the neurocognitive outcomes at discharge displayed a high cognitive and psychoemotional status variability. This paper presents the neuropsychological treatment concept we employed and discusses challenges encountered while treating critically ill patients with cognitive impairments.
Zusammenfassung: Bis heute konnte nicht ausreichend belegt werden, inwiefern schwer erkrankte COVID-19 Patient_innen von frühzeitigen neuropsychologischen Interventionen profitieren können. Nun wurden neuropsychologische und klinische Daten von N = 29 Patient_innen, die nach einer COVID-19-Infektion mit kritischem Verlauf in einer neurologischen Frührehabilitationsklinik aufgenommen worden waren, deskriptiv ausgewertet. Die meisten Patient_innen hatten die Diagnose einer Critical Illness Polyneuropathy (CIP), nur ein Drittel hatte eine zusätzliche Hirnschädigung erlitten. Alle zeigten ausgeprägte neuropsychologische Beeinträchtigungen bei Aufnahme, aber erzielten unter neuropsychologischer Therapie deutliche Verbesserungen. In Bezug auf Kognition und psycho-emotionalen Zustand war das Outcome bei Entlassung sehr heterogen. Im Folgenden wird das neuropsychologische Behandlungskonzept präsentiert und es werden besondere Herausforderungen in der Behandlung dieser Patient_innen diskutiert.
References
(2020). Central nervous system manifestations of COVID-19: A systematic review. Journal of the Neurological Sciences, 413, 116832. https://doi.org/10.1016/j.jns.2020.116832
(2022).
S3-LL Neurologische Rehabilitation bei Koma und schwerer Bewusstseinsstörung im Erwachsenenalter . InDeutsche Gesellschaft für Neurorehabilitation e. V. (DGNR) (Ed.), Leitlinien für die Neurorehabilitation. https://www.awmf.org/leitlinien/detail/ll/080-006.html(2022). CORO-NEURO-ICU study group. Delirium in adults with COVID-19-related ARDS: Comparison with other etiologies. Neurology, 10.1212. Advance online publication. https://doi.org/10.1212/WNL.0000000000201162
(2020). COVID-19 may induce cuillain-Barré syndrome. Revue Neurologique, 176(6), 516–518. https://doi.org/10.1016/j.neurol.2020.05.003
(2022). Fatigue and cognitive impairment in post-COVID-19 syndrome: A systematic review and meta-analysis. Brain, Behavior and Immunity, 101, 93–135. https://doi.org/10.1016/j.bbi.2021.12.020
. (2021). Assessment of neurocognitive functions, olfaction, taste, mental, and psychosocial health in COVID-19 in adults: Recommendations for harmonization of research and implications for clinical practice. Journal of the International Neuropsychological Society, 28(6), 642–660. https://doi.org/10.1017/S1355617721000862
(2001). Delis-Kaplan executive function system: Manual. Pearson Assessment & Information GmbH.
(2022). SARS-CoV-2 is associated with changes in brain structure in UK Biobank. medRxiv, 604(7907), 697–707. https://doi.org/https://doi.org/10.1101/2021.06.11.21258690
(2005). Leitlinien der Gesellschaft für Neuropsychologie (GNP) für Neuropsychologische Diagnostik und Therapie. Zeitschrift für Neuropsychologie, 16(4), 175–199. https://doi.org/10.1024/1016-264X.16.4.175
(2004). The JFK Coma Recovery Scale-Revised: Measurement characteristics and diagnostic utility. Archives of Physical Medicine and Rehabilitation, 85(12), 2020–2029. https://doi.org/10.1016/j.apmr.2004.02.033
(2010). Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Critical Care Medicine, 38(7), 1513–1520. https://doi.org/10.1097/CCM.0b013e3181e47be1
(2020). A paradigm for the pandemic: A Covid-19 recovery unit. NEJM Catalyst Innovations in Care Delivery. https://doi.org/10.1056/CAT.20.0238
(2021). Cognitive deficits in people who have recovered from COVID-19. EclinicalMedicine, 39, 101044. https://doi.org/10.1016/j.eclinm.2021.101044
(2023). The Leipzig treatment programme for interdisciplinary diagnosis and therapy of neurocognitive post-COVID symptoms: Experiences and preliminary results. Zeitschrift für Neuropsychologie, 34(2), 71–83. https://doi.org/10.1024/1016-264X/a000376
(2018). Anxiety, depression and post traumatic stress disorder after critical illness: A UK-wide prospective cohort study. Critical Care, 22(1), 310. https://doi.org/10.1186/s13054-018-2223-6
(2005). Two-year cognitive, emotional, and quality-of-life outcomes in acute respiratory distress syndrome. American Journal of Respiratory and Critical Care Medicine, 171(4), 340–347. https://doi.org/10.1164/rccm.200406-763OC
(2006). Assessing neurocognitive outcomes after critical illness: Are delirium and long-term cognitive impairments related? Current Opinion in Critical Care, 12(5), 338–394. https://doi.org/10.1097/01.ccx.0000244115.24000.f5
(2014).
Cognitive impairment following critical illness . In R. D. Stevens, N. Hart, & M. S. Herridge (Eds.), Textbook of post-ICU medicine: The legacy of critical care (pp. 204–215). Oxford Academic. https://doi.org/10.1093/med/9780199653461.003.0019(2010). Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA, 304(16):1787–1794. https://doi.org/10.1001/jama.2010.1553
(2022). AWMF S1-Leitlinie Long/Post-COVID [German S1 Guideline Long-/Post-COVID]. AWMF-Registernummer: 020-027.
(2020). COVID-19: A global threat to the nervous system. Annals of Neurology, 88(1), 1–11. https://doi.org/10.1002/ana.25807
(2013).
Neurologic implications of critical illness and organ dysfunction . In A. J. Layon, A. Gabrielli & W. A. Friedmann (Eds.), Textbook of Neurointensive Care, 409–425. https://doi.org/10.1007/978-1-4471-5226-2_21. (2018). Practice patterns and outcomes after stroke across countries at different economic levels (INTERSTROKE): An international observational study. Lancet, 391(10134), 2019–2027. https://doi.org/10.1016/S0140-6736(18)30802-X
. (2022). Physical, cognitive and mental health outcomes in 1-year survivors of COVID-19-associated ARDS. Thorax, 77, 300–303. https://doi.org/10.1136/thoraxjnl-2021-218064
(2010). Diagnostik von Bewusstseinsstörungen anhand der deutschsprachigen Coma Recovery Scale-Revised (CRS-R)
[Diagnosis of disorders of consciousness with the German version of Coma Recovery Scale-Revised (CRS-R)] . Neurological Rehabilitation, 16(5), 232–246. https://www.hippocampus.de/media/316/cms_4d120f96d147d.pdf(2022). Leitlinienbasierte Standards zur Struktur- und Prozessqualität neuropsychologischer Diagnostik und Therapie [Guideline-Based Standards for the Structural and Process Quality of Neuropsychological Diagnostics and Therapy]. Zeitschrift für Neuropsychologie, 33(3), 115–128. https://doi.org/10.1024/1016-264X/a000362
(2022). Post-acute sequelae of COVID-19 (PASC): A meta-narrative review of pathophysiology, prevalence, and management. SN Comprehensive Clinical Medicine, 4, 90. https://doi.org/10.1007/s42399-022-01167-4
National Institute for Health and Care Excellence (NICE) . (2022). COVID-19 rapid guideline: Managing the long-term effects of COVID-19. National Institute of Health and Care Excellence: Clinical Guidelines. Author. https://www.nice.org.uk/guidance/ng188(2020). Neurological implications of COVID-19 infections. Neurocritical Care, 32, 667–671. https://doi.org/10.1007/s12028-020-00978-4
(2017). Core outcome measures for clinical research in acute respiratory failure survivors. An international modified Delphi consensus study. American Journal of Respiratory and Critical Care Medicine, 196, 1122–1130. https://doi.org/10.1164/rccm.201702-0372OC
(2008). CVLT California Verbal Learning Test. German Adaptation. Manual. Pearson Assessment & Information GmbH.
(2022). Long-term cognitive functioning is impaired in ICU-treated COVID-19 patients: A comprehensive controlled neuropsychological study. Critical Care, 26, 223. https://doi.org/10.1186/s13054-022-04092-z
. (2013). Long-term cognitive impairment after critical illness. The New England Journal of Medicine, 369(14), 1306–1316. https://doi.org/10.1056/NEJMoa1301372
(2021). Neuropsychologische Störungen bei coronavirusassoziierten Erkrankungen. Erscheinungsbild, Diagnostik und Rehabilitation [Neuropsychological Disorders in Coronavirus-Associated Diseases: Clinical Presentation, Assessment and Rehabilitation]. Zeitschrift für Neuropsychologie, 32(4), 195–221. https://doi.org/10.1024/1016-264X/a000342
(2012). Wechsler Adult Intelligence Scale WAIS-IV – Fourth Edition, German adaptation. Manual. Pearson Assessment & Information GmbH.
(2020). Intensive care admission and early neuro-rehabilitation. Lessons for COVID-19? Frontiers in Neurology, 11, 880. https://doi.org/10.3389/fneur.2020.00880
(2022).
S2k-LL SARS-CoV-2, COVID-19 und (Früh-) Rehabilitation (“Living Guideline”) . InDeutsche Gesellschaft für Neurorehabilitation e. V. (DGNR) (Ed.), Guidelines for neurorehabilitation (Version 3.0, 2nd update, 1 November 2022). https://www.awmf.org/leitlinien/detail/ll/080-008.htmlStroke Unit Trialists’ Collaboration . (2013). Organised inpatient (stroke unit) care for stroke. Cochrane Database Systematic Reviews, 9(9), Article CD000197. https://doi.org/10.1002/14651858.CD000197.pub3(2016). Patient clientele and rehabilitation course in neurological and neurosurgical early rehabilitation: A comparison of 2002 and 2014. Aktuelle Neurologie, 43(9), 534–540. https://doi.org/10.1055/s-0042-117711
(2021). Delirium and neuropsychological outcomes in critically Ill patients with COVID-19: A cohort study. BMJ Open, 11(9), e050045. https://doi.org/10.1136/bmjopen-2021-050045
(2017). Post-intensive Care Syndrome: an Overview. Journal of Translational Internal Medicine, 5(2), 90–92. https://doi.org/10.1515/jtim-2016-0016
(2010). Memories and health-related quality of life after intensive care: A follow-up study. Critical Care Medicine, 38(1), 38–44. https://doi.org/10.1097/CCM.0b013e3181b42909
(2020). Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: A systematic review and meta-analysis with comparison to the COVID-19 Pandemic. Lancet Psychiatry, 7(7), 611–627. https://doi.org/10.1016/S2215-0366(20)30203-0
(2019). Long-term cognitive impairment after acute respiratory distress syndrome: A review of clinical impact and pathophysiological mechanisms. Critical Care, 23(1), 352. https://doi.org/10.1186/s13054-019-2626-z
(2016). Critical illness polyneuropathy (CIP) in neurological early rehabilitation: Clinical and neurophysiological features. BMC Neurology, 16, 256. https://doi.org/10.1186/s12883-016-0775-0
(2017). Critical-illness-Myopathie und -Polyneuropathie
[Critical illness myopathy and polyneuropathy] . Medizinische Klinik – Intensivmedizin und Notfallmedizin, 112(7), 589–596. https://doi.org/10.1007/s00063-017-0339-0(2009). Visueller und Verbaler Merkfähigkeitstest (VVM-2)..#. Manual. Swets Test Services.
(2023). Subjective and objective cognitive deficits in patients with post-COVID syndrome: A challenge for neuropsychologists. Zeitschrift für Neuropsychologie, 34(2), 99–110. https://doi.org/10.1024/1016-264X/a000374
(2022). Postacute sequelae of COVID-19 critical illness. Critical Care Clinics, 38(3), 455–472. https://doi.org/10.1016/j.ccc.2022.01.001
Society of Critical Care Medicine . (2023). https://www.sccm.org/Home(2020).
Diagnostik und Therapie von Gedächtnisstörungen bei neurologischen Erkrankungen, S2eLeitlinie . InDeutsche Gesellschaft für Neurologie (Ed.), Leitlinien für Diagnostik und Therapie in der Neurologie (pp. 1–82). Deutsche Gesellschaft für Neurologie. www.dgn.org/leitlinien(2022). Visual interpretation of brain hypometabolism related to neurological long COVID: A French multicentric experience. European Journal of Nuclear Medicine and Molecular Imaging, 49(9), 3197–3202. https://doi.org/10.1007/s00259-022-05753-5
(2022). Long COVID neuropsychological deficits after severe, moderate, or mild infection. Clinical and Translational Neuroscience, 6(2), 9. https://doi.org/10.3390/ctn6020009
(2023). Improving neuropsychological rehabilitation for COVID-19 patients: Guideline-based advances. Zeitschrift für Neuropsychologie, 34(2), 57–70. https://doi.org/10.1024/1016-264X/a000373
(2013). Cognitive dysfunction in ICU patients: Risk factors, predictors, and rehabilitation interventions. Critical Care Medicine, 41(9), 81–98. https://doi.org/10.1097/CCM.0b013e3182a16946
(2008). The Rivermead Behavioural Memory-Test – Third Edition (RBMT-3). Manual. Pearson Assessment.
(2020). Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: A single-centered, retrospective, observational study. Lancet Respiratory Medicine, 8, 475–481. https://doi.org/10.1016/S2213-2600(20)30079-5
(2012). Testbatterie zur Aufmerksamkeitsprüfung (TAP): Version 2.3 (3. Aufl.). Psytest. Vera Fimm, Psychologische Testsysteme.
