SCCM Resource Library-Case Exemplars of Post-COVID Recovery

Video Transcription

Hi there, and welcome to the concurrent session, Healing and Recovery Post-COVID, a Multiprofessional Perspective. My name is Erin Hall and I am a clinical health psychologist  at Geisinger Medical Center in Danville, Pennsylvania, and I work specifically for the Departments of Critical Care Medicine and Trauma Surgery.  I'm going to be sharing with you today a talk entitled Case Exemplars of Post-COVID Recovery.  I don't have any disclosures to share, and I just want to state that the views that I share are my own and do not necessarily reflect those of Geisinger Medical Center.  Before I get started, I just want to mention that I am a psychologist in an ICU, so I have a very different perspective than a lot of psychologists who typically do not have  any training in caring for or working with critically ill patients.  So I am sharing this from that perspective. So I work with patients both in the hospital and also in our post-ICU survivor clinic, and I also run a COVID survivor support group,  which is a virtual support group.  So we're going to talk a little bit about this today, and I'm speaking with two other psychologists who work in different settings with  critically ill patients and survivors as well.  So just to start out, our current post-ICU and hospital care structures are currently insufficient to adequately meet the needs of the COVID-19 survivor population.  And before COVID, we were not yet equipped to meet the needs of our ICU survivor population in general.  Comprehensive follow-up care will require a multidisciplinary perspective and approach. The traditional mental health system may not have  the resources or knowledge of COVID-specific and ICU-specific challenges  to meet the needs of survivors.  There is so much to be learned about the short and long-term psychiatric, neurologic, and physical outcomes in COVID-19 survivors, and for those of us that work with these patients,  we really have a true understanding that these cannot be separated.  So just a quick update on the literature, and there's vast amounts of literature and research that's come out about the COVID population.  So just kind of to highlight some of the pieces that are key in understanding neurocognitive recovery. Neurologic outcomes have been found to affect at least a third of survivors.  The most common symptoms have been found to include fatigues and myalgias, trouble with taste and smell, and persistent headache.  Interestingly though, the literature suggests, and I have found in my COVID survivorship population that it's also not just critically ill survivors,  but also non-hospitalized patients with COVID-19 have been found to have persistent neurologic symptoms. This study found brain fog to be the most common, followed by headache.  In my experience, this is also what I'm hearing from my COVID survivors, that the brain fog and the headache seem to occur  not associated necessarily with the severity of the COVID-19 illness.  Cognitive and psychiatric problems have been found to be present in a significant number of COVID survivors. The literature is similar to post-ICU syndrome,  and it's greater than a third of survivors.  At six months in this particular study, 34% approximately met the criteria for at least one psychiatric or neurologic problem, including anxiety, depression, PTSD, or insomnia.  78% of survivors were found with impairments in at least one cognitive domain at three months, with 50%, half of these patients, experiencing problems with executive functioning.  I think that we're gonna find here, just in my experience with the different waves of COVID and variants, that we will find some more significant psychiatric  and neurocognitive impairment in some of the groups versus others.  So COVID survivorship from the experience of survivors, I realize I have a relatively unique experience working on a critical care team with survivors,  getting to see patients in our survivor clinic, as well as weekly in my COVID survivor support group. And so I've learned a tremendous amount from these people, these survivors,  and I hope to inform the understanding of them in the acute phase as well.  So the cognitive symptoms of long COVID that I'm really hearing about are issues that come and go. There are some persistent issues,  but a lot of times people are noticing and reporting that at times they're better, at times they're worse. Dysfunction tends to depend on emotions.  It tends to be worse when people are upset, emotional or anxious. They'll notice in particular that they have more cognitive difficulties when they are more stressed or emotional.  They've also noticed a sundowning pattern to dysfunction, which is very similar to what we see in dementia, as well as in delirium in the hospital. When people are tired,  they experience more difficulties with cognition as well as with emotions.  Drawing a blank mid-conversation. This is reported and also observed in my group. Poor comprehension and difficulty focusing. Really general trouble with inattention  seems to be quite common.  Brain fog, as we saw reported in the prior study. This is pretty commonly reported and also very concerning for these patients. They are not functioning cognitively  at the level that they were at baseline and this creates distress. Finally, problems with planning and scheduling. Many of them are using planners or timers or alarms  set on their phone to help them remember when to take medications or do things that they didn't have to do before.  Also the slowed speed of processing. This kind of overlaps with brain fog. Just everything takes more effort and feels slower. Executive functioning problems.  This is transitioning from one task to another. Problems with planning, organizing, multitasking, interacting with technology, switching mental sets,  switching from one topic to another. And finally, memory disturbance. There's a lot of this reported. I also observed this in my survivors. Wondering, did I eat dinner last night?  Repeating stories that are important. Things like that.  Problems are reported to be more pronounced in the acute stages of COVID-19 and they may diminish over time, but in many cases do not return to baseline.  So how about the psychiatric symptoms of long COVID? What I'm seeing, we know long COVID is kind of an encompassing term that very much overlaps with post-ICU syndrome  and the symptoms of depression, anxiety, and PTSD. I'm hearing a lot of symptoms of depression and anxiety. Some specific, some general.  We'll talk a little bit more about some of those. New panic attacks, new social anxiety or anxiety leaving their house. Sleep disturbances and nightmares.  These often are associated with hospital stay and delirium and things that a person remembers from that time. Feeling frustrated often or angry.  People tell me they feel like they're kind of not in control of their emotions at times. Fatigue, anxiety and avoidance of going to the dentist.  This is one that we talk about quite a bit. Whether it is the suction at the dentist reminds them of certain things or just having people close to their mouths.  This is a commonly shared concern.  Avoidance of doctor's appointments or going to the hospital altogether.  Wearing a CPAP often triggers memories of the ICU admission whether it is reminiscent of the high flow depending on the nasal pillows or the experience that they have with a CPAP.  Feeling easily triggered to experience distress. Noticing a correlation between pain and mood where they feel very helpless and mood changes when they're in pain.  Avoidance of increasing heart rate or breathlessness. So avoiding the stairs, activities where they're gonna have to exert themselves, et cetera.  Challenges surrounding ability to return to work which threatens their sense of identity. Ongoing hallucinations and delusional beliefs or memories. Though this is more rare,  I've had people who are seeing colored lights and things flashing, seeing people on their front porch and disturbing memories of the ICU admission.  So just to touch on the physical and neurologic symptoms of long COVID, we've already talked about the loss of taste and smell, fatigue and weakness, diffuse muscle pain,  needing to rest often, daytime napping, physical limitations associated with the burden of rebuilding muscle mass and strength, persistent tinnitus, headache, very common,  numbness or tingling in certain parts of the body, dizziness, being unable to determine left from right when following commands or directions  and persistent GI distress or disturbance.  So these are many of the symptoms that I'm hearing and just to report from a firsthand. So now I'm gonna talk just about some specific cases of COVID-19 survivorship.  So Mr. J was a 50 year old male. He had no significant past medical history, very fit physically and in a very high profile  business job. He had had a mild case of COVID-19 where he was never hospitalized. After his illness, he began to experience pronounced cognitive difficulties in multiple domains,  including executive functioning, prioritizing demands, task switching, initiating and completing tasks and communicating effectively. Similar to a person recovering from a traumatic  brain injury, he began to avoid work so that others would not notice his deficits as he was used to functioning at a certain intellectual level.  He was advised to consider short term disability  and ended up not being able to return to work. So now Mr. B, he is a 50 year old male with a history of asthma. He had a prolonged ICU admission  and ended up receiving a bilateral lung transplant after COVID.  He continues to experience problems associated with his ICU delirium, problems with memories of his ICU admission, including nightmares, cognitive dysfunction, he has fatigue,  with a sundowning pattern where he is more forgetful at night, he's experiencing a lot of anger, trouble controlling his anger, and he feels that he's easily triggered to experience  emotional distress or outbursts. He is currently about eight months or nine months post his lung transplant. He has endured acute rejection as well.  And he's had an ongoing diagnosis of a chronic disease called Alzheimer's disease. He's had an ongoing fatigue due to global muscle weakness  and rebuilding of strength and has not been able to return to work. He actually just recently was approved for long term disability.  Ms. T is a 35 year old female who was hospitalized for two weeks with a superimposed pneumonia and prolonged course of Decadron. So she left the hospital on Decadron.  After her hospitalization, she continued to experience an altered mental status. She did not sleep per report for approximately two weeks.  Her husband brought her to the emergency room, reporting that she was experiencing symptoms of psychosis, including auditory and visual hallucinations.  The patient herself believed God was speaking to her and instructing to kill herself. She really had no insight into the psychosis  and was required a prolonged inpatient psychiatric hospitalization with antipsychotics.  And finally, Ms. K, she was a 50 year old former ICU nurse,  or current ICU nurse. She was diagnosed with COVID. She self-treated at home. She was doing self-proning. She was never actually hospitalized.  In the weeks following the acute illness, she noticed problems with recalling medications and doses at work. She would freeze up with things that she knows  that she knows and became concerned about her ability to care for patients. She was experiencing brain fog, memory impairment, headache, confusion, significant sensitivity  to light and sound, and trouble responding to directions. So her son would say, mom, move to the left and she would be very confused and unable to respond.  She was experiencing significantly increased anxiety, depression, and sleep problems as well. More in response to her deficits and inability to function  at her normal baseline, but was unable to return to work. She did end up returning very recently, approximately six months after her initial infection,  but not to a job as an ICU nurse.  These are just a few examples of many patients that I have come across. I wanted to share some diversity in cases and what recovery is like post-ICU.  Happy to answer any questions that you have and thank you so much for listening.

Video Summary

The current post-ICU and hospital care structures are not sufficient to meet the needs of COVID-19 survivors. Comprehensive follow-up care requires a multidisciplinary approach, as the traditional mental health system may not have the resources or knowledge to address the specific challenges faced by survivors. Neurologic outcomes, including fatigue, trouble with taste and smell, and persistent headache, have been found to affect a third of survivors. Cognitive and psychiatric problems, such as anxiety, depression, and PTSD, are present in a significant number of survivors. Common cognitive symptoms include brain fog, poor comprehension, and memory disturbance, while psychiatric symptoms include depression, anxiety, and sleep disturbances. Physical and neurologic symptoms may also persist in survivors.

Asset Subtitle

Infection, Patient and Family Support, 2022

Asset Caption

Recovery after critical illness remains challenging since the COVID-19 pandemic, given the traditional silos of healthcare system delivery. Characteristics of successful post-ICU clinic structures and referrals will be reviewed, and areas of ongoing implementation innovation will be discussed. Length of follow-up and support vary, and coordination of care among multiple specialties is often needed. Since the pandemic began, a large burden of survivors of critical care and long COVID syndrome has generated a heterogenous group needing follow-up. Speakers will review the current state of our understanding of post-intensive care syndrome and psychological recovery during the pandemic.

Meta Tag

Content Type Presentation

Knowledge Area Infection

Knowledge Area Patient and Family Support

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Rehabilitation Medicine

Tag COVID-19

Year 2022

Keywords

post-ICU care

COVID-19 survivors

neurologic outcomes

cognitive problems

psychiatric problems

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