Advances in Psychiatry

It hardly seems possible that three years have gone by since the outbreak of COVID-19. From the beginning, clinicians and scientists have sought to understand the short- and long-term effects on patients who contracted the virus. With the passage of time, insight into the disease and its consequences continues to emerge as researchers navigate the vagaries of SARS-CoV-2.

Early on in the pandemic, case reports about cognitive deficits in patients hospitalized with COVID-19 began to surface. At NewYork-Presbyterian/Weill Cornell Medical Center, Faith Gunning, PhD, and Abhishek Jaywant, PhD, psychologists specializing in neuropsychology in the Department of Psychiatry, were observing this in patients as well. However, the reports of the effect of COVID-19 – both the disease and its treatment – on cognitive functioning were anecdotal and generally not supported by objective measurements. Knowing the time-sensitive nature of addressing cognitive deficits early in the disease course, Dr. Gunning and Dr. Jaywant began conducting neuropsychological evaluations in a cohort of patients with COVID hospitalized at NewYork-Presbyterian/Weill Cornell during the first wave of the pandemic in New York City.

Dr. Gunning is also the George Alexopoulos, M.D. Honorary Directorship, Psychiatry, and Associate Professor of Psychology in Psychiatry, at Weill Cornell Medicine. Dr. Jaywant is Assistant Professor of Neuropsychology in Psychiatry and in Rehabilitation Medicine at Weill Cornell Medicine.

Dr. Faith Gunning

Dr. Abhishek Jaywant

Specifically, they conducted the assessments in medically stable patients with COVID-19 recovering from prolonged hospitalization that included acute inpatient rehabilitation. The findings of their study, which evaluated the occurrence and objective measures of cognitive deficits, were published in the December 2021 issue of Neuropsychopharmacology.

In 2022, Dr. Faith Gunning and Dr. Abhishek Jaywant were recognized with the Neuropsychopharmacology Editors' Award for a Transformative Original Report for their paper, Frequency and Profile of Objective Cognitive Deficits in Hospitalized Patients Recovering from COVID-19.

Characterizing Cognitive Difficulties After COVID-19

To help comprehend the extent of cognitive issues in this new population of patients, Dr. Jaywant and Dr. Gunning, with colleagues in psychiatry and rehabilitation medicine at NewYork-Presbyterian/Weill Cornell, explored several factors that might be involved. These included mechanical ventilation, already known to be linked to long-term deficits following critical illness; psychiatric illness; delirium in the intensive care unit; and associations of preexisting cardiovascular and metabolic diagnoses with cognitive functioning.

In their study, the team evaluated a cross-sectional cohort of 57 hospitalized patients with COVID-19 who required acute inpatient rehabilitation due to limitations in mobility and/or performing activities of daily living. Of these patients:

• Mean age was 64.5 years old
• 84 percent were living at home and were independent in activities of daily living prior to hospitalization
• Two patients had documented cognitive difficulties prior to hospitalization; none had documented dementia
• 64 percent had preexisting cardiovascular and metabolic diagnoses
• 88 percent of patients had documented hypoxia/hypoxemic respiratory failure and 77 percent were treated with intubation and mechanical ventilation
• 29 percent of patients were weaned off ventilation using tracheostomy
• All patients were significantly limited in basic mobility and activities of daily living requiring admission to the rehabilitation unit

Patients were evaluated by a clinical neuropsychologist or a neuropsychology postdoctoral fellow at an average of 6.6 days following transfer to the inpatient rehabilitation unit. Assessment focused on attention, executive functioning, and memory as these cognitive domains have not only been linked to functional outcome, but also have a relationship to inflammation, vascular processes, hypoxia, and mood and anxiety symptoms.

Results of the study showed:

• 46 of 57 patients (81 percent) exhibited objectively documented cognitive deficits, with attention and executive functions most affected
• Mild cognitive impairment was the most common, though moderate and severe cognitive impairment was also apparent in some patients
  • 11 patients (19 percent) had normal cognitive functioning
  • 27 patients (47 percent) had mild cognitive deficits
  • 14 patients (25 percent) had moderate cognitive deficits
  • 5 patients (9 percent) had severe cognitive deficits
• Rate of impairment in patients increased as tasks placed greater demands on executive functions
• Divided attention, set-shifting, and processing speed had relatively high rates of impairment
• Immediate recall, which places significant demands on working memory, had a high rate of impairment, whereas delayed memory and recognition memory were infrequently impaired
• Frequency of impairment was not related to the presence of chronic cardiovascular and metabolic disease
• After controlling for age, divided attention was not significantly associated with either intubation duration or time from extubation
• 4 of the 57 patients were diagnosed with ongoing delirium at the time of the neuropsychological assessment
• 34 of 57 patients (60 percent) did not meet criteria for a psychiatric diagnosis, which primarily included adjustment disorders
  • 13 patients (23 percent) had adjustment disorder
  • 2 patients (3 percent) had major depressive disorder
  • 6 patients (11 percent) had unspecified anxiety or mood disorder
  • 2 patients (3 percent) had preexisting psychiatric illness still present

“To our knowledge, this is among the first reports of objectively measured cognitive symptom profiles in a well-characterized sample of hospitalized individuals recovering from COVID-19.” — Dr. Faith Gunning, Dr. Abhishek Jaywant, and study authors

With regard to mechanical ventilation, which generally carries the risk of functional deficits in critically ill patients, the researchers did not detect a significant relationship with executive dysfunction in their study cohort. They suggest that because the duration of intubation after COVID-19 is significantly longer than in prior acute respiratory distress syndromes that at a certain point patients with COVID-19 may experience cognitive deficits regardless of the time of intubation. They also noted the absence of a positive association between time from extubation to assessment and divided attention was unexpected as one would anticipate progress in cognitive performance the longer that patients are off mechanical ventilation.

With results that indicate patients with COVID-19 commonly have impairments in attention and executive functions following prolonged hospitalization, the research has provided “an early benchmark for studying the evolution of cognitive difficulties in recovering COVID-19 patients.”

“Our findings have since been extended and replicated by other groups, and my mentor and co-author, Dr. Gunning, and I continue our work in this area,” said Dr. Jaywant when presented with the 2022 Neuropsychopharmacology Editors’ Award. “Our studies laid the foundation for further investigations into mechanisms and treatment of attentional difficulties after COVID-19.”

“This honor is especially meaningful to me given the dedication of the entire clinical research team and especially Dr. Jaywant, who had the foresight to measure objective cognitive concerns during routine clinical care at bedside during the height of the first wave of the pandemic in the U.S.,” said Dr. Gunning in accepting the award. “This recognition is particularly rewarding due to the team’s efforts that went above and beyond during such a challenging period. I couldn’t be more proud to be part of this important work.”