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2020 - Ajslp 20 00147
2020 - Ajslp 20 00147
Tutorial
Purpose: Severe acute respiratory syndrome coronavirus 2 Results: COVID-19 infection results in a combination of
is the virus resulting in COVID-19 infections in nearly (a) respiratory infection with mechanical ventilation secondary
4.3 million Americans with COVID-19 in the United States as to inadequate oxygenation, (b) inflammatory system reactivity,
of July 29, 2020, with nearly 150,000 deaths and hundreds of and (c) increased blood clotting factors. These affect
thousands of survivors (https://www.coronavirus.jhu.edu/map. central nervous system function incurring long-term cognitive
html). This tutorial reviews (a) what has been reported about communication impairment in a proportion of survivors.
neurological insults in cases of COVID-19 infection, (b) what is Diagnostic and intervention approaches for such impairments
known from similar conditions in other disorders, and (c) how are discussed.
that combined information can inform clinical decision making. Conclusions: The existing literature on cognitive sequela
Method: PubMed and the Cochrane Central Register of of COVID-19 infection is small to date, but much can be
Controlled Trials were searched for COVID-19 or other learned from similar viral infections and disorders. Although
coronavirus infections, cognitive impairment observed following COVID-19 is novel, the speech-language pathology approaches
critical care, and disorders for which intermittent or chronic to evaluation and intervention of other populations of critical
hypoxia is characteristic. These were combined with searches care patients are applicable. However, speech-language
relating to cognition, brain, and communication. All searches pathologists have not routinely been involved in these patients’
were conducted between April 8 and May 23, 2020. Meta- acute care. As such, this is a call to action to speech-language
analyses and randomized clinical trials addressing other critical pathologists to address the unprecedented numbers of
illnesses were also included to extend findings to potential patients who will need their services early in the disease
cognitive communication outcomes following COVID-19. process and throughout recovery.
H
umans around the world are facing their first those with comorbid health conditions (Richardson et al.,
pandemic in a century. The climbing numbers 2020). Although the current concerns of the health care
of people testing positive for the severe acute professions are on containing the spread of the virus and
respiratory syndrome coronavirus 2, the virus that causes saving lives, there is growing evidence that those who sur-
the COVID-19 infection, are grabbing the attention of the vive the battle with the virus may have long-term neurologi-
populous, driving social distancing to “flatten the curve” cal consequences (Needham et al., 2020; Pinna et al., 2020;
(CDC.gov). High rates of infection are leading to the over- Tsivgoulis et al., 2020; Wu et al., 2020). Thus, it is para-
crowding of hospitals and intensive care units (ICUs) and mount that health care professionals and speech-language
shortages of ventilators for patients and of personal protec- pathologists (SLPs), in particular, prepare to diagnose and
tion equipment for health care workers. There is known treat the cognitive communication disorders that may arise
increased risk of COVID-19 in individuals with other se- as a result of those consequences in COVID-19 survivors.
rious health conditions and elderly individuals, particularly The following tutorial provides background regarding
the potential for cognitive communication impairment as a
sequela of surviving critical, severe illness due to COVID-19
a
Department of Communication Sciences and Disorders, University infection. Although data are emerging daily about survivors,
of New Hampshire, Durham this novel coronavirus is too new to provide direct knowl-
Correspondence to Amy E. Ramage: amy.ramage@unh.edu edge for clinical decision making in speech-language pathol-
Editor-in-Chief: Julie Barkmeier-Kraemer ogy. For now, SLPs in the field are responding to each
Editor: Therese M. O’Neil-Pirozzi patient’s symptoms, and referrals are largely for dysphagia,
Received May 26, 2020
Revision received July 4, 2020
Accepted August 18, 2020 Disclosure: The author has declared that no competing interests existed at the time
https://doi.org/10.1044/2020_AJSLP-20-00147 of publication.
American Journal of Speech-Language Pathology • Vol. 29 • 1821–1832 • November 2020 • Copyright © 2020 The Author 1821
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Downloaded from: https://pubs.asha.org 182.185.29.179 on 09/11/2023, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
though there are reports in the ASHA Special Interest infections in Wuhan, Hubei Province, China, indicate that,
Group 2 forum and in the interim guidance from the of the 799 moderately to severely ill or critically ill patients
World Health Organization (2020) about delirium in ICU admitted to Tongji Hospital between January 13 and Feb-
patients with COVID-19. Thus, evidence from similar ruary 12, 2020, 113 died and 161 recovered. On admission,
conditions can help to guide our practice in this pioneering most (64%) patients who died and only 12% of recovered
age. This review will address (a) what has been reported patients had percutaneous oxygen saturations levels of < 93%,
about neurological insults in cases of COVID-19 infection, and all had abnormal chest radiographs with bilateral in-
(b) what is known from similar conditions in other dis- volvement in 100% of deceased and 94% of recovered
orders, and (c) how that combined information can inform patients (Chen et al., 2020). This is not surprising given
clinical decision making. What should become clear to the that the first symptoms of COVID-19 identified in the
reader is that, although COVID-19 is new, the speech- critical care literature were respiratory distress and in-
language pathology approaches to evaluation and treatment creased incidence of acute respiratory distress syndrome
of other populations of critical care patients are applicable. in COVID-19 patients (Chen et al., 2020). Disorders of
However, SLPs have not routinely been involved in these consciousness at hospital admission were also reported in
critically ill patients’ acute care. As such, this is a call to 2% of cases (Chen et al., 2020), suggesting possible central
action to SLPs to address the unprecedented numbers of nervous system (CNS) involvement even in the early stages.
patients who will need their services. Currently, there are only a few reports of an overtly
affected CNS in patients testing positive for COVID-19. In
such cases, the damaged brain tissue is seemingly separate
Method from the infection’s effects on the lungs or other organs.
This tutorial’s purpose is to identify the potential for For example, Poyiadji et al. (2020) reports on a woman in
brain injury and cognitive communication impairment in her late 50s, with severe presumptive COVID-19 presenting
survivors of COVID-19 infection as well as potential next with cough, fever, and altered mental state. Following sev-
steps for evaluating and treating such impairment. Because eral radiological assessments, she was found to have acute
COVID-19 is a novel virus with limited published research necrotizing encephalopathy, a rare complication of influ-
on its disease process, the potential for cognitive disorders enza and viral infections. Acute necrotizing encephalopathy
was also explored in other coronaviruses, as well as in sim- is associated with intracranial “cytokine storms” (immune
ilar disorders requiring critical care. Thus, to write this system hyperinflammatory process; Mehta et al., 2020) that
tutorial, database searches of PubMed and the Cochrane breakdown the blood–brain barrier and can result in sym-
Central Register of Controlled Trials were conducted using metrical, multifocal lesions of medial temporal and tha-
the MeSH terms COVID-19 or other coronavirus infec- lamic cortex. Recently, severe acute respiratory syndrome
tions, cognitive impairment observed following critical care coronavirus 2 also has been found in the cerebrospinal
(“critical care,” “delirium,” and “post–intensive care unit fluid in cases of COVID-19–related encephalitis (Moriguchi
syndrome” [PICS]), and disorders for which intermittent or et al., 2020; Poyiadji et al., 2020). In fact, hypoxic encepha-
chronic hypoxia is characteristic (i.e., “chronic obstructive lopathy was reported in 20% of deceased patients in Wuhan
pulmonary disorder” [COPD], “chronic obstructive sleep (Chen et al., 2020). Similar reports were seen following the
apnea” [COSA], and “mechanical ventilation”). The root Middle East respiratory syndrome coronavirus, with pa-
searches for each disorder were then combined with the fol- tients suffering severe respiratory infection, sepsis, organ
lowing subtopic searches: “brain,” “inflammation,” “magnetic damage, and blood clotting disorder (coagulopathy; Arabi
resonance imaging,” “cytokines,” “cognition,” and “executive et al., 2015; Mogi et al., 2017; Takanashi, 2009). Interest-
function.” The role of SLPs in the evaluation and treatment ingly, some symptoms (i.e., delirium, seizures, altered con-
of these disorders was also queried by including the terms sciousness) following Middle East respiratory syndrome
speech and language. Results of the database searches were coronavirus infections were described as “reversible” be-
filtered to include only those involving human participants cause they resolved within a month. Follow-up imaging
18 years of age or older, published in English, and including and assessment of mental status or cognition after dis-
experimental research studies and reviews. All searches were charge have not been reported in those cases.
conducted between April 8 and May 23, 2020. Other neurological consequences of COVID-19 may
relate to co-occurring increases in coagulation factors
(e.g., D-dimer and Fibrinogen levels), which are associated
Results with poor prognoses (Panigada et al., 2020; Ranucci et al.,
2020; Spiezia et al., 2020; Tang et al., 2020). This increase
Potential Neurological Consequences of COVID-19 in the potential for blood clotting appears to be infection
Hospitalizations for individuals testing positive for related, likely as a result of chronic inflammatory states
COVID-19 (4.6% of all cases in the United States) have and formation/deposition in the lungs of excess of fibrin
primarily been in those with cough, fever, and shortness (a protein activated when there is vessel wall injury to pro-
of breath (each accounting for > 80% of cases) as well as duce clotting to prevent blood loss; Weisel & Litvinov,
with gastrointestinal symptoms (in approximately 20% of 2017). These clotting factors appear to be spilling over into
cases; Garg, 2020). Data from the origin of COVID-19 the circulatory system, as they do in chronic obstructive
Q. Zhang et al., 2015) brain function. A coordinate-based is often accompanied by myopathy or polyneuropathy due
meta-analysis of brain imaging findings in COSA indicates to long-term debilitation in an ICU, along with psycho-
a convergence of brain tissue changes in the right amyg- logical comorbidities (anxiety, depression, and posttraumatic
dala and anterior insula, which are integral to brain net- stress disorder [PTSD]; Mart & Ware, 2020). Premorbid
works essential for sensory perception, emotion (anger, cognitive impairment is associated with the likelihood of
fear, happiness), interoception (air hunger [dyspnea], sex- further impairment after delirium, but even in those with
uality), and memory (Tahmasian et al., 2016). little or no impairment at baseline, delirium independently
predicted poorer outcomes (Francis & Kapoor, 1992).
Hypercoagulability Thus, the illness-related features that result in delirium
Virus-associated hyperinflammation is associated with likely alter brain function.
risk for blood clotting or sepsis-induced coagulopathy in There are at least four subtypes of delirium (Girard
the lungs, legs, and brain (Hess et al., 2020). Venous and et al., 2018) associated with separable mechanisms of action.
arterial thrombotic complications are estimated in as many These include the following:
as 31% of COVID-19 patients (Klok et al., 2020); there-
1. hypoxic: secondary to chronic or intermittent hypoxia;
fore, an influx of critically ill stroke patients with this pan-
demic is likely. As in other instances of stroke, physicians 2. septic: secondary to cytokine-mediated organ and
treating COVID-19 cases are considering the use of tissue brain damage due to microglial activation;
plasminogen activator and other anticoagulants (Klok 3. metabolic: secondary to renal or hepatic dysfunc-
et al., 2020) but are aware of the complexity of the cases tion; and
given the two other features—hyperimmune activity and
4. sedative related: secondary to use of medications in
hypoxia.
critical care.
Delirium These causative mechanisms alter the brain in differ-
Delirium is a cytokine-mediated activation of micro- ing ways. For example, positive end-expiratory pressure–
glia and astrocytes associated with acute brain dysfunction. induced impairment of cerebral venous outflow and systemic
It is characterized by quickly developing fluctuations in at- return can result simultaneously in increased intracranial
tention (focused, sustained, or shifting) and awareness (orien- pressure and reduced blood flow to the brain (Sasannejad
tation) and may also involve cognitive disturbance (“The et al., 2019). Cytokine activation of microglia may result
DSM-5 Criteria, Level of Arousal and Delirium Diagnosis,” in increased permeability of the blood–brain barrier and
2014, p. 5). Importantly, this fluctuation is particularly accumulation of amyloid-β (Sasannejad et al., 2019). All
characteristic of delirium and not seen in dementia or other four delirium subtypes may result in transient or permanent
forms of cognitive impairment (Hopkins & Jackson, 2006). changes in brain function, resulting in cognitive impairment
Delirium occurs in up to 70% of critically ill older adults months and years later.
in ICUs (Wang et al., 2018), and its presence and du- Delirium is further characterized by hyperactive, hypo-
ration is the strongest risk factor for the persistence of active, or mixed states. The hyperactive state is characterized
cognitive impairment following recovery. Its presentation by anxious or agitated behavior with increased psychomotor