Neuropsychological and Functional Impact of COVID-19 on Mild Cognitive Impairment

Abstract

We present a case report to showcase that behavioral, cognitive, and functional decline may be associated with COVID-19 stay-home guidance among older adults with pre-existent cognitive impairment. In a functionally independent and physically active older adult with Mild Cognitive Impairment, there was worsening in depression and anxiety symptoms associated with the restrictions of COVID-19. Functional decline was also noted as assessed by Instrumental Activities of Daily Living. We discuss solutions to mitigate the effects of COVID-19 restrictions in this vulnerable population.

To the Editor

The Corona virus disease (COVID-19) has rightfully resulted in widespread stay home/shelter in place recommendations which could range from mere annoyance to a potential healthcare crisis for older adults. Loneliness is common in older adults even when they are living independently and in close proximity with others. ¹ Loneliness is associated with feelings of helplessness, powerlessness, and vulnerability. ¹ COVID-19 quarantines have the potential to further isolate people resulting in negative psychological effects including post-traumatic stress symptoms, confusion, and anger. ^2,3 In a community sample of young adults, over half of the respondents rated the psychological impact of the COVID-19 emergency as “moderate” or “severe.” ⁴ In another study of young adults, 29% of respondents indicated experiencing “high” or “very high” levels of stress, a percent that far exceeds that of pre-pandemic levels. ⁵ Those that have pre-existing cognitive impairment and live alone may be at higher risk of psychological decompensation due to stay-home guidance compared to those that do not have cognitive impairment and live with family. We present a case of behavioral and functional decline in an older adult with mild cognitive impairment (MCI) and depression after COVID-19 stay-home guidance was placed.

Mr. S. was a 75-year-old retired lawyer with MCI who lived alone in the community and had a longtime girlfriend who was actively involved. At baseline, 6 months ago, he was independent in performance of his basic Activities of Daily Living (ADLs) ⁶ and Instrumental Activities of Daily Living (IADLs) ⁷ and was physically active, jogged 3 miles daily, and played pickleball regularly. He had authored 9 books in the past and his girlfriend hoped that he would be able to finish his memoir during the COVID-19 physical restrictions. His comorbidities included hypertension, hyperlipidemia, chronic kidney disease, depression, and low back pain. His depression was controlled with mirtazapine. During his initial in-person evaluation 6 months ago (pre-COVID confinement), cognitive, behavioral and functional assessments were performed by a multidisciplinary team. His scores on the Modified Mini-Mental State Examination ⁸ were 97/100; 28/30, and the New York University Paragraph Immediate and Delayed Recall Test (NYU-PRT) were below 8 and 6 respectively. The NYU-PRT is a measure of episodic prose recall and is a good predictor of cognitive decline. ⁹ The Neuropsychiatric Interview ¹⁰ was positive for depression and anxiety, and Geriatric Depression Scale (GDS) (30 items) score was 10. ¹¹ He was fully independent with scores of 6/6 on ADL, and 8/8 on IADL.

After he was homebound for 6 weeks due to the COVID-19 restrictions, his girlfriend noticed worsening in his mood, sleep, memory, and function. A remote visit over telephone was arranged per the COVID-19 clinical policies of the Department of Veterans Affairs with the memory disorders clinic to assess and manage his situation. The patient and his girlfriend were initially interviewed separately and later together by the memory clinic team consisting of a geriatrician, a neuropsychology technician, and a geriatric psychiatrist. There were no medical problems or psychosocial stressors noted in the interim.

Patient’s girlfriend reported that he was depressed due to COVID-19 as he could not go out. She noted that he had difficulty sleeping, balancing his checkbook, and that his apartment was cluttered. His social interactions were limited to his girlfriend, as she urged him stay home to avoid exposure. She did all his grocery shopping due to fear of him contracting COVID-19. On questioning for depression, he reported newfound symptoms of helplessness, worthlessness, feeling the future was bleak, indecisiveness, not enjoying getting up in the morning, and avoided social gatherings. He was previously very active with his book publishing community and reported he was avoiding them lately. He did not connect with them as he did before. He described worsening irritability, anxiety, and sleep in the context of the COVID-19 pandemic. He also reported declining memory and heightened relationship strain. He reported frustration regarding his inability to focus and constant preoccupation with news-updates about COVID-19. He was particularly distressed that he had to depend on his girlfriend for grocery shopping. He was also quite concerned about his children and grandchildren getting exposed to COVID-19. All assessments done at baseline not requiring the use of paper and pencil to complete, were repeated over the phone after 6 weeks of COVID restrictions. A repeat GDS over the phone was 21/30 compared to the baseline score of 10. Epworth Sleepiness Scale score worsened to 8 from the baseline score of 6. ¹² Despite the report of worsening in memory, his score on the NYU-PRT did not change.

The treatment team recommended use of trazodone for insomnia, monthly mental health appointments via phone and the use of technology to mitigate loneliness in this patient as technological interventions are proven to be effective to combat loneliness. ¹³ It is known that social networks mitigate the detrimental effects of loneliness by enhancing physical and mental health. His girlfriend was successful in establishing connections with his grandchildren with whom he enjoyed talking over the phone. He also connected with his girlfriend and family members over FaceTime and Zoom calls. Another important factor was loss of physical activity as he used to jog for 3 miles daily at baseline. He was afraid of using a treadmill due to fear of loss of balance. Although home exercise programs that include strength, balance, and aerobic exercise are ideal during COVID-19 restrictions, timed walking in his own backyard was encouraged in this patient.

Behavioral, cognitive, and functional decline may be associated with COVID-19 stay-home guidance among older adults and is a pressing problem. Similar to our patient, others have found that patients with MCI living alone are particularly prone for negative psychological effects and sleeping problems. ¹⁴ Approximately 15% to 20% of people age 65 years or older have MCI and about a third of them live alone. ^15,16 Routine screening for loneliness and psychological distress at healthcare visits is important in this cohort. ¹⁷ Assessing the strength of social connections could give valuable information. Relying on only one person as reported in this case may be a red flag for increased caregiver burden especially in the context of prolonged physical distancing. A reliable source of collateral history is important in older adults especially with cognitive impairment to obtain accurate information about cognitive and functional decline and to titrate the frequency of interventions. Developing social connections using technology and regular counseling could be a potential solution to the COVID-19 stay-home guidance in older adults. ^13,17