Transcription:
Neurological Effects of Long Haul Covid

Melanie Cole (Host): Welcome to Back to Health, your source for the latest in health, wellness, and medical care. Keeping you informed, so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole. And joining me today is Dr. Anna Nordvig. She's an Assistant Professor of Neurology at Weill Cornell Medical College, Cornell University, and an attending neurologist at New York Presbyterian Hospital, Weill Cornell Medical Center, and she's here to talk to us today about the neurologic effects of long COVID.

Dr. Nordvig, thank you so much for joining us today. As we're talking about the effects of long COVID, I'd like you to tell us a little bit about what that is. What does it mean? And what are you seeing as far as these symptoms and these complications?

Dr Anna Nordvig: Melanie, thank you so much for having me here. It is a true honor to be with you on this podcast. Long COVID is a term that we use in the medical field to describe when patients are suffering from symptoms that originated from an acute COVID infection at about three months beyond the initial infection. We have learned that sometimes the actual COVID infection can persist not just for weeks, but even sometimes a few months. So, we really think about long COVID as developing three months and beyond, and sometimes we've seen symptoms persist now years after the initial infection.

That said, some people get over the acute illness within a week or two, and you could say their long COVID symptoms begin right after. Oftentimes, the neurological complications begin right away during acute COVID. And other times, we see them beginning in weeks one or two or even three after the acute COVID infection began.

And what are we talking about here when we say neurological? Well, as I tell my patients in our outpatient post-COVID Brain Fog Clinic, which is part of our general memory disorders clinic, we really think about the nervous system and the neurological system as kind of twofold. One is what happens inside the brain itself, the brain being the neurons and all the supportive tissue. And then, the other is all of the projections from the brain. The brain itself, we call the central nervous system and all of those projections you might hear about as the peripheral nervous system. And COVID, unfortunately, seems to affect all of the above, the brain itself as well as all of the peripheral nervous systems. And when I say that, I mean the motor system, the one that helps you to move your arms and legs and pick up that delicious morning bagel on a cold day in Chicago. Then, your sensory system, the one that allows you to feel a gust of wind on your skin or a warm cup of coffee in your hands. But also, much less talked about your autonomic nervous system, which is the nervous system that helps you live every day, helps your heart decide how fast to beat and your eyes decide when to blur or not, or your saliva decide when to make your mouth dry or not, or when you feel lightheaded because your blood's not getting to your brain fast or hard enough.

So, we have seen complications across the board. We have even seen many patients with complications who had very mild COVID. And in the early days, we thought that there was a link between how severe your acute COVID illness is, like those people that really had to be hospitalized and what happened afterwards. But we quickly started to see that even mild COVID cases or asymptomatic COVID cases developed long COVID.

And so, what are we actually seeing? We're seeing these central nervous system effects. The most common one is actually something we call encephalopathy. And what does that really mean? Well, most of my patients come in and they say, "I have brain fog," and so that's the term that I use too. It is not a new term. I think we started making a list of 15 or 20 different conditions that used the term brain fog to describe its symptoms. And that list has evolved to over 50 conditions. But one of the most common that we used to know before this version of coronavirus, SARS-CoV-2, came around is myalgic encephalomyelitis, which is otherwise known as chronic fatigue syndrome, which we think is due to a number of different viruses that cause persistent neurological effects. Now, that is just one complication. And that kind of brain fog, it might start even before any other symptom of acute COVID, especially in some of our older patients, where like in other regular viruses, confusion may be the very first symptom of something off. And we see patients being brought in because they just seem a bit more confused and we realize, "Hey, they're infected with COVID." Now, some of those patients, the confusion will clear thankfully. But others, it may continue. And so, that's kind of one flavor of a long COVID brain fog.

Another flavor is people who are younger and have no prior confusion or really clear preexisting conditions, they also are developing these cognitive changes. And those are, I think, seen more typically in the literature that describes long COVID cognitive dysfunction. And what do I mean by those? Well, the brain has different ways to express its ability to think. One way is called executive function. And that includes things like processing what people are saying, like how well you are processing what you're hearing today, being able to follow multiple people speaking at once, understanding quickly what you've read as quickly as you used to, being able to express yourself without mistakes, ordering things, prioritizing, finishing tasks you started, and even paying attention, which is related to executive functions. Our patients are having a lot of trouble with all of these things, and this, like I said, can even persist years into a long COVID syndrome.

But that's not all. Sometimes we also do start to involve the areas of the brain that deal with memory and those symptoms can include things like difficulty finding the word you want to use, talking around the word or potentially even forgetting what was just said or what you just learned or heard or read. And those, although typically thought of as memory functions, also have to do of course with how well you're actually paying attention at the time, how tired you are, how fatigued you are at the time. And there is a particular symptom that we see in long COVID, which we call fatigue, and it's not just physical fatigue. It's also cognitive fatigue.

We have lots of conditions where this can happen. One I'll point out is a post-traumatic brain injury or post-concussion, like from motor vehicle accident or chronic concussions from sports playing. We have patients who also have this. And in that field, that's called cognitive intolerance. It just means that the more work, the more thinking that your brain is doing, the more tired it gets, and people just don't have the capacity that they used to.

Now, your initial question was, well, you know, what are all of the different complications of neurological long COVID? Well, I've only really talked about one so far, the brain fog and the associated cognitive fatigue. Of course, in the media, initially with acute COVID, other more acute complications like stroke were reported, and that would be strokes where the brain lacks enough blood to regions or strokes where there's bleeding.

We also have seen, of course, other types of neurological conditions that are more related to the rest of the nervous system, not just the brain. And that includes things like movement conditions like Guillain-Barré syndrome. We have a number of patients who developed peripheral neuropathy, which means that all of those different three nervous systems that control the rest of the body and how it's functioning are impaired and people are having trouble sensing things with their hands or feet or moving or even their bodily functions. And actually, it has emerged that that autonomic nervous system may hold one of the keys to even understanding brain fog, in that in some of our patients, we notice that their brain fog, which can be associated with migraines and ear ringing, which we call tinnitus, or even some different aches and pains in their face or sharp shooting pains, all of these things, sometimes even aches in their shoulders or a lightheadedness when they stand up that makes them feel less attentive and more tired in their thinking, these things can also be associated with a problem in the autonomic nervous system. The term that we use to describe this is dysautonomia and that may be something that patients find helpful when they read about it. People read about all of the different functions of the autonomic nervous system and they say, "Hey, that's me." and when we bring patients into our clinic, we actually do screen for all of these things because it can help us to treat long COVID.

I think it's also very important to highlight that while this segment is focusing on neurological effects of long COVID, there are very important psychiatric effects and behavioral effects of long COVID as well. And I would argue that those are inseparable when it comes to the mechanism, the actual underlying changes in the brain. We have lots of evidence that shows that there is a neuroinflammatory process, where the body gets inflamed first. And in some patients, for whatever reason, may it be that they have a genetic predisposition or maybe they had a preexisting immune disease or inflammatory disease of the body or the brain, we haven't identified all the different reasons, but they're different from what makes people susceptible to acute COVID. And for this reason, people may not be able to cure themselves of the systemic inflammation. The body's just not as good in some people at calming down that systemic inflammation, that COVID is very sneaky in being able to do much better than other viruses.

And in those second or third weeks when we know those inflammatory markers in the blood really skyrocket in some patients, we think that the blood brain barrier, which is that connection between the blood that's coming from the body into the brain and the big, strong wall that's built to protect the brain from things leaking into the brain, starts to loosen up and break down because of all of that inflammation, and the body almost starts to attack itself. And we call that autoimmunity. And when the autoimmunity and the inflammation break down the blood brain barrier, we think that these molecules, they transcend the wall, they get into the brain and they activate the brain's immune system.

Now, lots of viruses we think do that. You know, when I think back to all of my kids and just how irritable and cranky they used to be whenever they got a cold. It was always like, "You are going to be up all night with these kids just because of how cranky they are." You start to wonder, you know, how many viruses out there really do cause an encephalopathy or change in the inflammatory system of the brain. But the reality is, most of the time, the brain knows how to handle that and it cures it within a few days or so. In this case, we think that COVID like some other more serious infections out there, the inflammation that it causes in the brain just persists. It just hangs around and it seems like it's this subclinical kind of mild, brewing inflammation that just continues to activate itself. And when the immune system of the brain is activated, it causes the neurons, so the main cells of the brain that control your thinking, they start to dysfunction and malfunction and that can manifest, we think, in all of these brain fog areas that I've mentioned and also in mood and in personality. So, the mood component and the behavior component we think are also driven by that inflammatory process.

Melanie Cole (Host): This is absolutely one of the most fascinating podcasts I have ever recorded. And you have a voice that is so gorgeous, I could listen to it forever. You're a really great educator, Dr. Nordvig. So as we're talking about this and you've given us so much to think about with brain fog and all of these other neurologic complications, what can be done for patients with these long COVID symptoms? Is there a treatment? Is there a way to clear some of that brain fog?

Dr Anna Nordvig: So Melanie, we have been wondering this since early 2020. And some of the information that we have now actually comes from the numerous prior coronaviruses that afflicted humans and animals in the last century. But currently, this is what we try to do for our patients.

Number one, we acknowledge. We shed light on the fact that this condition exists. And believe it or not, for probably the first year plus of my work, I spent most of the time just helping patients understand that this symptom is absolutely a neurological condition and we need to recognize it.

And I have to give credit where credit is due. The patient advocacy for long COVID, especially on the brain fog side, has been astounding. The patients, a lot of them who have decided to make their voice heard, they've really stepped up. There are many groups like Body Politic, Long COVID, SOS, Dysautonomia International. I could go on and on. And there's even a Project ECHO Long COVID and Fatiguing Illnesses Group. These groups are just incredible at shedding light and actually quantifying symptoms to teach the doctors, the neurologists, the psychiatrists, the general doctors.

What do we do in clinic? So when a patient is able to actually get an appointment in a long COVID clinic, which I know is really missing in this country, in the world, and there needs to be more of, I think the first thing is actually cataloging all of the symptoms. And a lot of that comes from the doctor's questions, but it also comes from patients just bringing in lists of symptoms. And it may be things that you think are unrelated. Things like ear ringing or headaches we didn't necessarily know were associated with the cognitive side of things and patients were the ones who taught us that these things come in clusters. So, that's the first step, is actually getting through all of the different changes in the body.

Two is repurposing. Right now, one of the main goals in treatment is not just to say, "Hey, give it time and it'll all just get better." It's to try to repurpose treatments that we have from all of those other conditions that I mentioned to you that also caused signs and symptoms of chronic neuroinflammation. So, what do I mean by that? Well, if a patient, for example, has severe anxiety, which is new or worse or severe inattention or executive function difficulties after being afflicted with acute COVID, then use the existing medications, the oral drugs, some of the infusion therapies, even and more importantly sometimes, the behavioral therapies, the occupational therapy, and something called cognitive occupational therapy, the psychotherapy, all of the treatments that we already have in our toolkit, and repurpose them to treat each individual symptom. You know, we're using the gamut of migraine medications, of neuropathy medications to really try to address each individual symptom. And some of those do help with the neuroinflammation as well.

On the brain fog side in particular, we also are repurposing absolutely medications from the memory disorders world. And I would be remiss in doing this podcast and not mentioning that I do have some patients, probably about 10% of my brain fog clinic who had the onset of what the media describes as a typical brain fog. And they're maybe in their 70s or 80s or even a bit younger. And when they come in for their doctor's appointment, we realize that what they've done has probably unmasked an underlying neurodegenerative disease that they may have had a predisposition or family history for. And what they think is just a brain fog and needs to be treated that way actually needs to be treated with the medications and treatments we have for neurodegenerative disease. And what I mean is things like Alzheimer's, et cetera.

Now, I don't want to cause any alarm. Of course, the majority of people who get brain fog post-COVID do not have Alzheimer's or any of those neurodegenerative diseases, and I can't say that enough. But there are some who do, and I think it's important to not ignore that can happen, especially in patients who are in middle and older age and have them just assessed and have a neurologist look for the red flags that might indicate that they need that further workup because it changes prognosis, it changes everything.

Melanie Cole (Host): Wow. There's so much that goes into this. It's such a complex issue, and I guess we're still just learning so much about it. So, Dr. Nordvig, as we wrap up, can you just briefly give your advice to listeners about what they should be thinking about? What you would like them to do, if there's any lifestyle, if there's any things we can do? Does exercise help? Does rest help? Meditation? Anything to calm the mind or help clear the fog? Just give us your best advice on the neurologic complications of long COVID.

Dr Anna Nordvig: It's my pleasure. And for better or worse, I happen to be in a field where every single day I feel like I'm having this conversation, whether it be with a patient or a family friend. And here is what I do and I actually start at the acute COVID phase. So, the conversation goes like this. I have someone give me a call and they say, "Hey, I think I've been exposed to COVID," or "I have COVID." And I think that the treatment to prevent or at least decrease the effects of long COVID actually should start right there. Now, I don't have evidence behind that. Everything else I've said has evidence behind it. This I don't think we have as much data for, but I truly believe that focusing on this risk of systemic and the neuroinflammation very early on can help decrease the effects of long COVID and indeed getting vaccinated and being more careful around not getting infected with COVID as many times -- we used to say ever, but now we say as many times -- as you might, are two very important strategies from the get-go.

But if you are suffering from a COVID infection as we all have, most of us, then you focus on an anti-inflammatory and a more restful lifestyle. And what do I mean? Well, first, take it easy. So, don't push yourself through this particular infection like you would any other cold. Think about the medications that in some countries, like the US, are out there to try to decrease some of the symptoms of long COVID, that are available for certain groups. Talk to your primary doctor about that.

Then, focus on eating healthy, picking anti-inflammatory foods, decreasing your alcohol intake. And in terms of exercise, you know, this is quite controversial and the advice has really changed from the beginning. We used to say, "First rest and then just gradually increase exercise, it's going to help." Some patients can't tolerate the exercise, and it might be because they have dysautonomia and their body just doesn't know how to react to the exercise and it really fatigues them. But maybe starting to work, if long COVID begins and it's been couple weeks to months, really being careful working with a trainer therapist to gradually build in the exercise, monitoring fatigue levels, heart rate, blood pressure. You can also do that on your own at home. Those are all really important things.

Making sure you get enough sleep. I mean, I know insomnia, I didn't mention it earlier, but it's such an important and big symptom of acute and long COVID. And working on sleep hygiene, lots of techniques you can look up there. Cognitive behavioral therapy specifically for insomnia, working on sleep hygiene techniques like getting good rest, kicking people or pets out of the room even that interrupt your sleep if you can, even separating rooms. Whatever you can do to focus on your rest in those initial months is critical because sleep is a time when your brain is healing itself.

Other things, so chronicle your symptoms, make detailed symptom diaries, bring those to your doctors. And be willing to try different medications. We've only really talked about the western. There are eastern therapies including acupuncture and herbal medicines. There are lots of other experimental therapies out there. So, be open to all of that and try different things. Don't just kind of resolve yourself to, "Well, this is just how it is. My body will take time." Some people do, yeah, sure. People use meditation. We know that that can be helpful, but be willing to mix different therapies from different areas. And if one doesn't work, don't give up. You might be more sensitive to medications now than you ever were before and try another.

And keep tabs on other weird symptoms like if your hair falls out or you have allergies that are new post-COVID. And also, follow up with your primary doctor about other long COVID symptoms, the things we haven't talked about that aren't considered neurological, specifically lungs and heart, any of those conditions, shortness of breath, abnormal heart rate, et cetera, difficulty catching your breath. Those are all things that, of course, can affect the brain as well and your thinking. And those need to be treated with just as much care and attention.

Melanie Cole (Host): Wow. Thank you, Dr. Nordvig. This was so informative and I can just hear what a lovely, compassionate physician you are. Your patients are lucky that you are their physician. So, thank you for all of this information that you've given us. It was so comprehensive and really for sharing your expertise. Thank you again for joining us.

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