Good morning. I'm really excited today to share our presentation, COVID, Cognitive and Psychological Manifestations in Patients in Acute Rehabilitation. Along with our panel, we will discuss some important findings in taking care of patients who've had COVID-19 and are then being taken care of in rehabilitation facilities. My name is Susan Walter. I'm the Vice Chair for PNR at the Zucker School of Medicine at Hofstra Northwell. I'm the Medical Director of Inpatient Rehabilitation at Glencove Hospital. Today, I will talk a little bit about cognitive impairment in COVID survivors. But first, I'd like to talk a little bit about what causes cognitive impairment and psychological impairment in patients that have had critical illness. I think this will set a stage for our next speaker, who will focus more on COVID-induced delirium and cognitive impairments. I have no disclosures. Today, we'll describe the cognitive and psychological sequela of post-intensive care syndrome, describe the current literature on cognitive impairment in COVID-19 patients, and present our data on cognition and psychological well-being of patients admitted to acute inpatient rehabilitation after surviving COVID-19. What causes cognitive and psychological impairment in patients that have had critical illness? There is something called PICS, post-intensive care syndrome. This is defined as new or worsening physical, cognitive, or mental impairments in a patient following critical illness or intensive care, and is fairly widespread. As Dr. Su said, I'm sorry to say that sadly, it's true that bangs up and hangs up can happen to you, but they really happen to patients who are admitted to the ICU. The ICU, obviously, is there to save people's lives, but critical illness really takes a toll on a patient's physical and cognitive well-being. 74% of ICU survivors diagnosed with ARDS have some cognitive impairment, and 25% have that impairment after six years. 10% to 50% of ICU survivors express symptoms of depression, anxiety, PTSD, and sleep disturbance, which may actually persist for years. This affects every aspect of a survivor's life, including return to work, their relationships with their families. 50% of ICU survivors may need caregiver assistance up to one year later. The physical and psychological sequelae of ICU illness is pretty profound. The question is, why does this happen? In 1944, there was an article published in JAMA called ICU Rehab, A New Phenomenon. Basically, in this article, it talks about how the benefits of early ambulation were really clear. Morale was improved, general health and strength was maintained, and confluence was more rapid. Basically, this article described that immobility in the ICU, complete bed rest, was terrible for patients. How are we doing now? I think we've all had quite a lot of experience seeing consultations in the ICU during the COVID surges. We know that patients, for the most part, tend to be immobilized. Between 1903 and 1969, we went from first flight to putting a man on the moon. And yet, 70 years later, we're still largely immobilizing and sedating our patients in the ICU. What are some of the effects of critical illness? I want to just go over some of the physical effects because I think they'll help us understand why patients are so mobilized in the ICU, and that can contribute to their psychological and cognitive health. Critical illness obviously leads to bed rest in conjunction with having inflammatory cytokines, malnutrition, neuromuscular abnormalities, all of which lead to muscular weakness. Often, this is not picked up in those patients that are still intubated. For example, if you don't mobilize someone, even when they're on the vent, they can continue this vicious cycle of inflammatory state, neuromuscular weakness, leading to decrease in physical function, and that may not be picked up until a patient is moved off the vent. When we look at the long-term cognitive impairments of critical illness, it's actually really startling to see how many of our patients in medical and surgical ICU are in high risk for long-term cognitive impairments, and especially those patients that experience delirium. We know that patients who are on the vent very frequently experience delirium, and this is something that we'll talk about in a minute, but those patients are at a really high risk of developing cognitive dysfunction. That cognitive dysfunction, even at 12 months, can be seen similar to that of a moderate TBI or even patients with mild Alzheimer's disease. So what are some of the clinical manifestations? Cognitive, including deficits in attention, concentration, mental processing speed, executive function of memory, and psychiatric include anxiety, depression, PTSD, and sexual dysfunction. When we look at outcomes, quite a lot of data done on cognitive and psychiatric sequela of being in ICU, so majority of cognitive recovery occurs between the first six to 12 months, and 40% of ICU survivors have some cognitive impairment at three months and 34% at 12 months. This poor cognitive function is also linked with psychiatric impairment, inability to return to work, and decreased quality of life. Then when we look at their psychiatric side effects, these patients have anxiety, depression, PTSD, and their health-related quality of life is low. One really important thing for us to differentiate between is cognitive dysfunction and delirium. We cannot perform any cognitive testing on a patient that has delirium, and as someone who used to do consults in the ICU, I become quite comfortable with assessing for delirium, and I think this is something that every rehabilitation physician should be able to do. What is delirium? Delirium is not cognitive dysfunction. It's a disturbance of consciousness, and it's defined by the reduced ability to focus, sustain, or shift attention. In addition, there's usually a change in perceptual disturbance that is not accounted for by a pre-existing cognitive problem, including dementia. Delirium evolves over a very short period of time, and it tends to fluctuate. Somebody does not have the same delirium status over the course of the day. It tends to kind of come and go. We know we see this frequently in the sundown, and delirium is reversible. Delirium is caused by a medical condition, a medication, and something in the patient's environment. How do we assess if a patient has delirium? The next couple of scales have been validated for use in ICU and something that we use in our ICUs every shift. The first thing is something called the RAS scale. The RAS scale basically sees how sedated is the patient. Are they alert or are they sedated? It goes from negative five to plus four, but basically, we will primarily look at the patient if they are scoring negative three or better. If they're moderately sedated, lightly sedated, restless, or agitated, we can kind of proceed to do a delirium assessment. If a patient is deeply sedated, we're not going to be able to proceed with our delirium assessment. The very first step is to do a RAS scale and then proceed to the CAM ICU if the patient scores negative three or better. The CAM ICU really tells us does the patient have delirium or do they have some kind of other problem. The first thing we're going to look at, we're going to see do they have fluctuating mental status because this is the key to delirium. If the patient does not have fluctuating mental status, do not proceed with the CAM ICU. They do not have delirium. If they have fluctuating mental status, we want to check their attention. Do they have any attention? We ask them to squeeze our hand when we say the letter A. If they're able to talk, if they've been extubated, they can read the following sequences of letters. We can give them a sequence of letters. Then we look to see how many errors in attention they have. If they don't have two errors or worse, then they do not have a delirium. Look for other reversible causes of their medical status. If they have more than two errors and they are alert, then we can proceed to see if they have disorganized thinking. If they have more than two errors and they are not alert, that puts them into the delirium category. Then we check to see for disorganized thinking. We ask, will a stone float on water? Are there fish in the sea? Again, we check to see how many errors they have. If they have more than one, they are positive for delirium. I know this sounds like this takes a long time, but actually this is really quick to do and really, really important for those patients that we may want to consider to mobilize. Even on an event, if a patient is not delirious, they're a great candidate for early mobility, which will ultimately help with their cognition. Then when we look at the connection between delirium and cognition, there's definitely a relationship. When we look for the adjusted verbal cognition score, which can pick up even mild cognitive dysfunction, and we compare that with the days the patients had delirium in the hospital, we can definitely see that the more days that you had delirium leads to decrease in your score. Some of the things we may want to think about are, what are the things our patients experience that lead to persistent cognitive and psychological problems? They have hypoxia, they have pain, they have inflammatory cytokines, they have PTSD, they have delirium. Always together, definitely put them at long-term risk for cognitive and psychological dysfunction. Another thing that we need to talk about is PTSD. PTSD is characterized by having been exposed to some perceived life-threatening event and subsequently developing intrusive recollections of the events, leading to hyperarousal syndrome. In patients that have survived the ICU, the prevalence of PTSD has been described to be up to 40%. Frequently, patients will remember that they were delirious and they were imagining that things were done to them, that they were hurt, that they were mistreated, and this can actually lead to long-term PTSD. Again, what are the things that can cause PTSD in the ICU? Obviously, ICU therapies expose our patients to extreme stressors, respiratory insufficiency, pain with endotracheal intubation, that inflammation that is so common in regular patients, but even more so in patients with COVID, a strainer hypothalamic pituitary adrenal access, administration of catecholamines, steroids, delirium associated with psychotic experiences, and really limited ability to communicate and limited autonomy. We look at the two-year cognitive, emotional, and quality of life outcomes in ARDS, which has probably been studied the most when it comes in the ICU. You can really see how stark those decrements are, that even two years post-discharge from the ICU, patients have decrements in their cognition and in their emotional state. Just to summarize, cognitive and psychological effects of patients in the ICU are very prevalent. 70% of patients discharged from the ICU have cognitive impairments, 50% may have psychological impairments, and they are at high risk for long-term problems. Cognitive impairments include attention, concentration, processing speed, executive function, and psychological impairments, and include anxiety, depression, and PTSD. Thank you very much. We'll hold all our questions until our last speaker is finished, and I'm now going to hand over the mic to Dr. Opark. Thank you, Dr. Marcia. I'm going to share my screen. Good morning. My name is Muyeon Opark. I'm Chief Medical Officer and Senior Vice President at Berk Rehabilitation Hospital White Plains in New York. I'm a professor in the Department of Rehabilitation Medicine, Albert Einstein College of Medicine, and Montefiore Health System. Today, I would like to talk about the implementation of delirium care, especially during the COVID-19 pandemic, so from more hospital operation side. There are three key points I would like to discuss. It's the significance of delirium on the post-acute care setting during COVID-19, the framework for the high-quality implementation of delirium care, and the challenges and solutions of implementation systematic way, especially in the inpatient rehab side. Before I discuss the delirium care during the COVID-19 pandemic, I would like to talk to you briefly about the Burke Rehabilitation Hospital to help your understanding about this topic. Burke is 150 bed academic rehabilitation hospital with 10 outpatient sites with a residency program and two fellowships. We are part of Montefiore Health System and academically affiliated with the Albert Einstein College of Medicine. Our patients are referred not only from the Montefiore Health System, but also from other health care systems in New York, Connecticut, and New Jersey. This is a map showing our attachment area from New York City to the Hudson Valley region of New York State, serving those patients who need rehabilitation services. West Chester County, New York, was the epicenter of the pandemic during the first wave. This slide represents the number of COVID-19 cases and the actions taken from March 16th, 2020, when we had our first case and by mid-April, the number of cases rose to 90, which is actually two-thirds of our 150 bed at Burke. Already in the pandemic, we recognized the rehabilitation needs of physical, cognitive, and psychological domains, including the increasing number of patients with delirium. This was the New York Times article reporting the epidemic of delirium during the COVID-19 pandemic, alerting the public about its seriousness. Delirium increased up to 70 percent during the COVID-19 pandemic, and 28 percent of the older adults presented to the ED with delirium as the initial symptom of COVID-19 disease. It is hypothesized that restricted human contact and also use of potent tranquilizers for anxiety, agitation, and also staff distress and shortage, and the PPE use, which obscures their faces and muffles their voices, contributed to this increase. Delirium is also one of the most expensive medical conditions. The annual cost estimation was $152 billion in 2011. This is a study showing the cost of delirium care using the CMS data. The x-axis is the time from the hospitalization, and y-axis is the cost of care. The solid line represents the cost of the delirium group, and the dotted line represents the non-delirium group. It is expected that the cost will be higher among the delirium group during the acute hospitalization. But what is striking is that the cost of the care for the delirious patients remain to be much higher than the non-delirious patients. Even after discharge, and the gap between the two appears to be widening in post-acute care. This is another reason why we should pay attention to this topic in the post-acute set. This is a slide showing the information about how the information itself will not have any value until it's being utilized properly. We want to spend the next couple of minutes on the framework of a high-quality implementation and the work of our organization. The first step of knowledge to action process is really about identification of the problem. This is not just a problem of one person. This should be a problem of everybody from the CEO to the frontline staff, and this problem should be big enough and severe enough that everybody in the organization would like to fix it. The next step is based on the literature. Small pilot should be done in the local context. Even if it was worked in other place and published in the literature, that plan may not work in a different organization and different context. Always anticipate the barriers in advance and that will make the progress more efficiently and avoiding the situation like a death on committee, which we sometimes see it. The next step is monitoring the knowledge used and evaluating the outcomes. Outcomes speaks for itself. Sustaining the knowledge use is the hardest step and related to the cultural change. And that's really come to the change and innovation the fabric of the organization. And this is a iterative process. And every time you complete the circle, more knowledge is generated for the next project. For high quality implementation, we need the three systems. The system sounds fancy, but it's actually, it just actually means people with the specific responsibilities. The role of synthesis and translation system includes extraction of the evidence from the literature and translating that knowledge into user-friendly format. And coming up with a strategy of implementation. The delivery system includes each discipline champions who provides education, also the frontline staff who actually will carry out the activities of delivering screening or care. Finally, the support system are individuals in this performance improvement in this performance improvement and also management who ensure the quality of the training, monitoring the progress and also incorporating the care into the EMR. The key to success is frequent and clear communication among these systems to ensure that the system is all aligned and heading toward the right direction. This is a slide showing the plan and process of implementation. The first step is really about making this delivery care as a institutional priority. We have so many priorities, don't we? So having this as a priority from very top to the frontline clinical workers will be the key to success and select champions from each discipline and start a small pilot project and discuss the feasibility. This step may take the longest as long as months, sometimes for a year. The last step is monitoring the process and outcomes including validity of the staff's assessment and constant dialogue for how to make it sustainable. So I would like to tell you that the CMS actually one of the major challenges and the measures we have to do in October 1st, 2022 will be the delirium screening. So my simple messages are number one, the impact of a high quality delirium care can prevent negative outcomes and enhance patient family experience and potentially save healthcare cost. The high quality implementation is possible using well thought out planning, resilient approach in getting buy-in from all disciplines. Thank you so much for listening. And the next speaker will be Dr. Erica Trovato. Well, thank you everyone. My name is Erica Trovato. I am the director for the brain injury rehab program as well as the director of the brain injury medicine fellowship at Burke Rehabilitation Hospital. My part of the presentation will be focusing on management of delirium in a COVID positive patient during the first wave of the epidemic, as well as giving a brief overview of some of the literature that is now being published regarding delirium care during the COVID epidemic. I have nothing to disclose. And so we're gonna start off by talking about what is the usual standard of care for delirium, which really has been well established and there exists clinical guidelines that really with a focus to minimize the incidents as well as the prevalence of delirium in our patient population. A good mnemonic that I typically will utilize is PINCHME, which really stands for looking at different factors that could be contributing to the causes of delirium in our patients. So PINCHME stands for pain, infection, nutrition, constipation, hydration, medication use, as well as environmental factors. What's most important to not only being identifying these different factors that may be contributing to delirium, but is also recognizing as a team that we must always be reevaluating for all of these different factors. Delirium can come on quite acutely and different factors may play a different role. As we have clinicians, we know that the state of a patient can rapidly change and we want to be anticipating what may be coming. For example, if a patient is in pain and we are treating them with pain medications that may end up constipating the patient, we should be anticipating this. Likewise, we need to be looking at medication lists at all times for medications such as benzodiazepines or narcotics, which may worsen the delirium trend at that point for the patient. Regulation of the sleep-wake cycle is oftentimes overlooked, but this is a very significant problem for our patient population. As we know in the acute care hospital, they oftentimes are not getting good rest. So they come over to the rehab setting and they have a dysregulated wake cycle. And at that time, these are things that we should be focusing on. Very easy, but somewhat overlooked concepts of turning off the lights at night, making sure that the blinds are open in the daytime and closed in the evening time. Make sure that you're asking them to turn their TVs off as well as their phones that may be at bedside. Let's not forget the basics as well. If a patient is utilizing eyeglasses, prior to them being hospitalized, let's make sure their family is bringing that in for them. Likewise with hearing aids, because this really ensures proper orientation for the patient. Let's make sure that we're minimizing tethers and cords and IV lines so that we're able to ambulate the patients as quickly as possible. And likewise, we wanna make sure that we are providing appropriate hydration and nutrition. A lot of times patients will come over and they're extremely fatigued from their time in the acute care hospital. And now we're saying, okay, you need to get up and do three hours of therapy a day. Well, these patients are tired. And so we wanna make sure that in between their periods of rest, that we're providing them adequate nutrition and that we're really trying to emphasize as much interaction as possible. So we have our standards for good practices and guidelines to follow when it comes to identification and for management of delirium. However, COVID really forced us to pivot our usual processes like never before. And as guidelines and recommendations were changing constantly, so too was our appreciation for how COVID-associated delirium grew significantly. So we had our challenges that really presented themselves to our usual standard of care. I feel like this might, it wasn't too long ago, but yet it feels like a lifetime ago when the epidemic first started. And at that time, the information that was coming to us was so new and changing at all times. So this led to a lot of anxiety and fear. It was at a time when we had limited equipment and staff for bedside rehabilitation therapies and mobilization. There were safety concerns given isolation of patients that may have had acute on chronic cognitive deficits. We had lack of family support and socialization. Nobody was coming in. Nobody was going out. It was a difficult time to say the least. And we really saw a lot of burnout early on in our staff. And it was a challenge. If nothing else, we came together and we provided excellent care, but it was a bit of a trial at first. And that's where I'm going to now talk about a case that I had personally managed early on within the epidemic, the pandemic, I should say. And this was an elderly woman. She was 81 years old. She had a history of diabetes and dyslipidemia as well as gout. She had presented to the emergency room with confusion, fever, and generalized fatigue for one week. She had had a head imaging at the time and it had just shown some chronic lacunar infarcts. And she was inevitably diagnosed with COVID-19 encephalopathy as well as pneumonia and a urinary tract infection on March 29th, 2020. Again, think about how early on this really was in the pandemic. She received azithromycin and ceftriaxone for her COVID-19 pneumonia and Bactrim for her UTI. And then she was transferred over to Burke on April 3rd. Again, a very short period of time after having been diagnosed, placed on treatment, and then sent over. I wanna just highlight also that Burke as well as Northwell were at the epicenter of the first wave of COVID. Since then, we've treated and discharged over 550 patients with COVID. And this case is really helping to really describe what the first wave looked like in regards to those patients that we were receiving as a post-acute center. So when this patient came in on physical examination, she was Spanish speaking. She had a BIMS of three. She did not follow any commands. She was impulsive. She was distractible. She was disorganized. And she was very unsteady during her ambulation with intermittent losses of balance. She had poor safety awareness, really no insight into her deficits, and was very combative at times with staff. So throughout her stay, especially early on, we did quickly note some trends, including agitation. And we did have to use at that time an enclosed bed to ensure her safety as well as the safety of our staff. And if we think back to the beginning of this pandemic when PPE was in short supply, the basics were rationed. They were conserved across the board, including our staffing. At this time, it was also, this would be a typical patient that we would want to have on a one-to-one or constant observation. But this also posed a very difficult ethical dilemma across healthcare, really, was the subjecting of a staff member to someone who was COVID positive in a very small space. At this time, she was in a private room due to isolation precautions. And since she was Spanish speaking, and we didn't have dedicated technology at that time for all of the different patients that we had, the use of a translator we knew was paramount and very important. However, it was something that we were having difficulty initially. Her inconsistent behavior precluded her participation in therapy. And it was oftentimes very unpredictable. She had recurrent infections, typically in the form of a urinary tract infection. Because again, this would be a patient that we would typically have on a toileting schedule. We would have that one-to-one or constant observation provided that where we could really track her. But it was a delicate balance between keeping her safe and also keeping staff safe in the sense of the isolation precautions. Her stay with us was prolonged. If we can think back to when we didn't know how long someone was actually infected or how long they were able to transmit the virus to someone else, we would continuously test her because there was no guidelines at that time. So it was something, it was a case where we really rode the wave in regards to what the guidelines and the recommendations were. And as much as we were teaching her, she was teaching us about what was going on with COVID beyond that of a respiratory condition. So in regards to the patient-centered approach, we really, as with all of our patients, are idiosyncratically adapting for every single patient. We had to pivot and we had to realize that we needed to adapt under these circumstances. So what did we do? From an environmental standpoint, it was actually a large component to our management for this patient. We moved her from a private room into a semi-private room with another COVID-positive patient. And this was really to help with socialization and human interaction, something that we had taken so much more for granted and something that we were trying to re-implement and reintroduce for our patient. We were lucky enough to have our administration support the hospital with dedicated equipment in the form of iPads that we could provide to patients whose primary language was not that of English so that we could ensure that she would have technology available during therapy sessions and also for ways of communication with family. We utilized dedicated staff as much as possible so that the patient was able to build a rapport with the therapy staff as well as the nursing staff and the physicians as well, which really was able to provide some trust and provide some familiarity on a daily basis which was oftentimes missing in the beginning of this pandemic. Recreation therapy, which is such an important and vital discipline for rehabilitation overall, really played quite an important role for this patient as we were realizing that more and more social interaction and ability to provide therapies in the form of personal interests for the patient was really beneficial to her as well. We involved her family virtually as much as possible. We integrated them into the therapy sessions. They provided reassurance. They really were helping to support us in the recovery of their loved one. So in the form of behavioral adaptations, Burke is also very lucky to have had the administrative support for nonviolent crisis intervention training in our therapy as well as our nursing staff, which is really quite important in the sense that we're able to help manage these patients in a way that is most beneficial to them to help with their safety as well as that of the staff. We wanna be able to handle patients that have delirium and may have an agitated state along with that. So our staff that developed the rapport with this patient were those that were NVCI trained. We really tried to minimize restraints as much as possible. And again, we spoke about the constant monitoring provided by the staff members. But what we also have here at Burke is a video monitoring, I'm sorry, camera monitoring system that was able to provide oversight of the patients because again, they were behind these closed doors just further enhancing the isolation and the uncomfortable feeling it is that you can't physically see a patient that is within a delirium state. We had constant daily team huddles to try to craft and hone our behavioral strategies across our multidisciplinary team. And that's something that I think we're really proud of as the leaders of the team, but really helping to bring the team together and individualize our treatment approaches and our management approaches, and then communicating that with the patient and then with the staff as well. So what did we learn through this time? We learned that we must, as always, constantly review and adjust our medications, use consistent staff, again, to build that rapport, anticipate triggers, anticipate behaviors and effective means of providing patient-centered care. We reduced isolation as much as possible, whether it was from a shared room perspective or if it was integrating recreation therapy. We integrated family early and often, which was very beneficial across the board once we were able to figure out the logistics from a technology perspective. The same was for addressing language barriers, which oftentimes family felt like they were helping with their loved one and staff, so they would provide that translation. We adjusted the way that we delivered therapy. So what we did was instead of, let's say, having three one-hour sessions of therapy a day, we would cut them to 30-minute sessions, but have them more frequently throughout the day, which provided more time of social interaction between the patient, the therapy staff, and as well as the physicians. Our interdisciplinary team remained quite flexible, and it oftentimes had to think outside the box, yet within the constraints of COVID, which really was challenging, but something that really, I think, in the end has helped us learn different techniques for approaching these types of patients. So we thought, okay, great, you had COVID, you survived, you're okay, you'll get back to baseline, and life will go on. Well, I'm not sure if everyone remembers, but back in May of 2020, there was the first tweet by a woman named Elisa Perego in Italy, and she used the term of hashtag long COVID. And this was on Twitter, and she was using this to describe her own experience with continuing symptoms of COVID-19 even after recovery. However, it's now moved through various social media platforms to formal clinical experts and policymakers, and it's gained reasonable consistency in a description of the phenomenon with what's going on with prolonged symptoms of COVID. So now it may be known as post-acute COVID, ongoing symptomatic COVID, chronic COVID, post-COVID-19 syndrome, long haulers, and the post-acute sequelae of SARS, or also known as PASC. So what is involved with long COVID? One of the descriptors are the neurocognitive deficits, also known as brain fog. So one of the descriptors of brain fog is an umbrella term used to describe a constellation of cognitive functional impairments such as confusion, short-term memory loss, dizziness, and an inability to concentrate. Well, what's impressive also now is that once this started gaining some traction, it does appear as though there started to be some national recognition. So in February 20, I'm sorry, February 23rd of 2021, there was a NIH initiative that was launched to look into long COVID. And it really speaks to that national recognition of long COVID and the impact that COVID-19 has had beyond that of the acute phase. Research is now supported under this NIH initiative to have a better understanding of the pathophysiology regarding the chronicity of certain symptoms in the wake of COVID, including neurocognitive deficits. So really, what are we also learning now from studies that have been published? And they're starting to come out more and more now, and there's more guidelines that are gonna be developed based on this information that is being shared around the world. So this is one study that was recently published that was a retrospective cohort study, and it included over 273,000 COVID-19 survivors. And it used electronic health records from this population of patients diagnosed with COVID-19. And it estimated that the risk of having long COVID features in up to six months after diagnosis of COVID-19. The long phase was described as symptoms between three and six months, or 90 to 180 days. So this is one of the graphics that they had published, and this is basically showing that the incidence of each of these nine core symptoms of long COVID over time from initial diagnosis to six months after. The light pink portion of these graphs indicates the incidence of a particular symptom within the first 90 days or three months. The moderately pink color denotes a symptom occurrence between three months and six months only, and the dark pink color denotes that of a symptom experienced over the entirety of the study period from time of diagnosis up through six months. So what I've circled in blue is that of the cognitive symptom or core symptom from long COVID. And what this is demonstrating is that cognitive symptoms are observed in 7.88% of patients after their COVID-19 diagnosis, with a larger proportion of these patients reporting cognitive symptoms within the first three months compared to three to six months. Although there is a portion of these patients that did experience these cognitive symptoms from time of diagnosis up through six months. Another study that's been recently published is the Longitudinal Neurocognitive and Pulmonological Profile of Long COVID, or the COVID Immune Clinical Study Protocol. And this was really the first study that included both objective and comprehensive longitudinal analysis of neurocognitive sequelae from COVID-19. It's essentially a study utilizing a cohort of 150 patients and 100, I'm sorry, 50 patients that are without COVID, 50 patients that were of mild disease and then 50 patients with severe. And the preliminary group comparisons indicates that there's worse word list learning, verbal recall, and verbal recall of long delayed and verbal recognition in both patients with mild symptoms as well as more severe symptoms compared to the healthy control group. And that was both adjusted for age and for sex. So in regards to future directions, well, where are we going from here? The AAPMNR has put together an advisory group that is essentially looking at long COVID and basically putting together some resources in regards to guidelines for management of these different symptoms. They recently were able to publish on the treatment of fatigue. And I believe that the neurocognitive deficits that we are now seeing in regards to COVID, there'll be guidelines coming out for this in the near future as well. And these are my references. And now I'm going to hand over the mic to Dr. Carly Rothman. Thank you for your time. Good morning, everyone. Thank you, Dr. Travato. My name is Carly Rothman, and I recently completed my residency at Northwell Health as chief resident. And I'm now doing my fellowship in pediatric rehab at the University of Colorado. So today I'm going to continue the discussion on the cognitive and psychological effects of COVID-19 by presenting data that we have from a retrospective analysis that we performed at Northwell. So the objectives for today are to present data on cognitive and psychological wellbeing of patients admitted to acute inpatient rehabilitation post COVID-19 and discuss directions for future research. Our research questions were, what are the clinical and demographic characteristics of patients admitted to acute rehabilitation after hospitalization for COVID-19, and which variables, if any, correlate with impaired cognition, depression, and or anxiety in patients upon admission to acute rehab after hospitalization for COVID-19? In this retrospective analysis, patients with a primary diagnosis of COVID-19 requiring admission to acute rehab were included. Exclusion criteria were a primary rehab diagnosis unrelated to COVID-19, a patient who did not speak English or Spanish, and a patient who did not have any neuropsychological testing performed. We collected demographic information, including age, gender, level of education, level of independence, as well as multiple variables of the hospital stay, including medications and the need for ventilatory support and or ICU care. Upon admission to acute rehab, screenings for cognitive impairment, anxiety, and depression using the MOCA, GAD-7, and PHQ-9, respectively, were performed by a neuropsychologist fluent in English and Spanish. The PHQ-9, or patient health questionnaire, is a screening tool used to identify patients who need further testing for major depressive disorder or other depressive disorders, and can also be used to monitor symptoms and assess symptoms over time. It is scored from one to 27, with higher scores indicating more severe depression. Higher PHQ-9 scores are associated with decreased functional status and increased symptom-related difficulties, sick days, and healthcare utilization. The GAD-7, or generalized anxiety disorder assessment, is used to measure or assess the severity of generalized anxiety disorder. It is scored from zero to 21, with higher scores indicating more severe levels of anxiety. Further evaluation is recommended with scores of 10 or greater, and it is validated for primary care patients, the general population, and adolescents with general anxiety disorder. The MOCA, or Montreal Cognitive Assessment, is a screening tool for detecting cognitive impairment. It is validated in the setting of mild cognitive impairment, and has subsequently been adopted in numerous other clinical settings. A correction is available for patients with less than 12 years of education, and higher scores indicate more severe cognitive impairment. We started with 136 COVID-19 patients that were admitted to our inpatient acute rehab center, of which 105 met inclusion criteria. Data was collected by reviewing the electronic medical record, and then analyzed using PRISM software. Analysis of cognitive impairment, anxiety, and depression using the MOCA, GAD-7, and PHQ-9 were performed upon admission to acute rehab, and correlated with age, gender, length of stay in acute care and rehab, medications received, and need for ventilatory support or intensive care. Looking at the demographics of the sample, you can see that the majority were male, with a mean age of 59.78 years old. Most patients were listed as independent prior to hospitalization, and only five patients had a known history of stroke or dementia. The median acute care length of stay was 38 days, and the median acute rehab length of stay was 16 days. 58 patients had brain imaging performed, of which 20 or 34% had acute abnormal findings, such as a stroke. The majority of patients were admitted to the acute care hospital for respiratory failure due to COVID-19. Three patients were admitted for stroke, four for AIDP, four for generalized fever and weakness, and one for metabolic encephalopathy. Taking an initial look at the results from all age groups, you can see that the vast majority, 89% of our sample had an abnormal MOCA screening score on admission to acute rehab. Also notable, 75% of patients had a score on the PHQ-9, which is an animal or mild depressive symptoms. When broken down by age groups greater than or less than 65 years old, we can see that patients over 65 had lower MOCA scores and higher GAD-7 and PHQ-9 scores. Using a Spearman correlation, we can see that there was a statistically significant positive correlation between GAD-7 and PHQ-9 scores. Alluding to higher rates, patients who had anxiety were also more likely to have depression. Of note, there was not a significant correlation between these scores and their rehab length of stay. When comparing the MOCA, GAD-7, and PHQ-9 scores to individual patient demographics and variables of hospital stay in patients over 65, the MOCA scores were significantly higher in patients who received benzodiazepines and opioids and significantly lower in patients who received antidepressants. We did not find any significant correlation in the under 65 age group for these variables. When looking at patients of all ages who had brain imaging performed, such as CT or MRI, median GAD-7 scores were significantly higher in patients who had any evidence of abnormal brain imaging, either acute or chronic, compared to those who had normal brain imaging. When looking at the entire sample of patients, patients who received stimulant medication scored lower on the MOCA as well. And finally, when comparing PHQ-9 scores of the entire sample, female patients had statistically significant higher median PHQ-9 scores compared to males. To summarize, our results thus far show that among all patients admitted to acute rehab, there was a statistically significant positive correlation between GAD-7 and PHQ-9 scores. There were higher GAD-7 scores indicating higher levels of anxiety in patients with abnormal brain imaging, higher PHQ-9 scores indicating higher severity of depression in female patients, and significantly lower MOCA scores indicating cognitive impairment in patients who received stimulant medications. In patients over 65 years old, MOCA scores were significantly higher indicating less cognitive impairment in patients who received benzodiazepines and opioids, and significantly lower indicating more cognitive impairment in patients who received antidepressants. We did not find any statistically significant correlation between ICU care, ventilator requirements, steroid use, and the MOCA GAD-7 and PHQ-9 scores. Limitations of our study included the inherent limitations of a retrospective review and retrospective study and chart review, especially accounting for missing data from patients who came from outside institutions. We also did not indicate the cumulative dose of medications that patients received. For example, one patient might have received one dose of Ativan during their entire hospital stay, whereas another patient might have received multiple doses of different benzodiazepines, and they were all marked the same as yes. To conclude, the majority of patients were admitted to acute rehabilitation due to primarily respiratory complications from COVID-19 rather than a primary neurologic diagnosis. Among these patients, most had some degree of cognitive impairment and depressive symptoms. Cognitive impairment was more prominent in the elderly over 65 year old population, and depressive symptoms were more common in female patients. Patients with depressive symptoms were more likely to also have anxiety symptoms, and among the patients who had brain imaging performed, those with abnormal findings were more likely to express symptoms of anxiety. There is some evidence to suggest that medications such as opioids, benzodiazepines, antidepressants, and stimulants may impact cognitive scores in COVID-19 patients, however, more research is needed to further clarify these possible relationships. In our final manuscript, I'm looking forward to sharing the data I have presenting today, as well as a further multivariate analysis of the data and further analysis of how scores on the MoCA, GAD-7, and PHQ-9 screening tests may predict functional progress during acute rehabilitation by comparing it to GG scores done on the MoCA, and prior to discharge. We are also planning for long-term follow-up with these patients after discharge. While this study is focused on patients who are hospitalized for COVID-19, I believe it is worthwhile to investigate patients who are not hospitalized, as Dr. Travato mentioned, but now suffered from the so-called Longhauer syndrome. Are cognitive and psychological screening tests useful in this population as well? In the acute rehab setting, we often work with very vulnerable, elderly, and medically complex patients who have had long hospital courses. Both on the acute care side and within our rehab units, our dedicated physical, occupational, and speech therapists, nurses, respiratory therapists, nurse practitioners, and physicians put themselves at risk to go into room after room to help patients get moving and recover. That said, we can always look forward to what we can do better in the future. We can continue to intervene at the acute care level to promote early recognition of agitation and delirium and maximizing non-pharmacologic interventions. Screening recovering patients for cognitive impairment, depression, and anxiety is reasonable, time and cost effective, and so that they can be provided with appropriate treatment. This may help increase independence and functional activities and return to work. These are my sources. Thank you. Thank you so much, Dr. Rothman and all our speakers. We'll take some questions now. I see there's already a couple of questions in the chat. First question is, why was the MoCA picked and is used for mild cognitive impairment? So Dr. Rothman, if it's okay with you, if I take that question. The reason we picked the MoCA, we actually were in our spring surge and had to kind of improvise on the fly. And this is what we thought would be the fastest and the easiest for a neuropsychologist to do as he frequently administers the MoCA as part of his routine neuropsychology evaluations. I agree with you that if this was a prospective study, there are other batteries that could be used. And in regards to the second question, were any patients given imantadine? Yes, that was actually the only stimulant medication that we recorded that any of the patients thought was imantadine. Any other questions from anyone? Please feel free to put them in the chat. Okay, well, thank you. Oh, I think if there's no other questions, we'll wrap it up. Thank you so much for joining us today.

cognitive manifestations

psychological manifestations

acute rehabilitation

COVID-19

cognitive impairment

depressive symptoms

anxiety

screening

functional recovery

patient care