Letter to the Editor
Characterization and management of cognitive and emotional alterations in COVID-19 critically ill patients after ICU discharge
Caracterización y abordaje de las alteraciones cognitivas y emocionales en el paciente crítico COVID-19 al alta de UCI
G. Navarra-Venturaa,b,
, J. López-Aguilara,b, L. Blancha,b, S. Fernandez-Gonzaloa,c
Autor para correspondencia
a Critical Care Center, Parc Taulí Hospital Universitari, Institut d’Investigació i Innovació Parc Taulí-I3PT, Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain
b Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
c Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain
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Navarra-Ventura, J. López-Aguilar, L. Blanch, S. Fernandez-Gonzalo" "autores" => array:4 [ 0 => array:4 [ "nombre" => "G." "apellidos" => "Navarra-Ventura" "email" => array:1 [ 0 => "gnavarra@tauli.cat" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J." "apellidos" => "López-Aguilar" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "L." "apellidos" => "Blanch" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "S." "apellidos" => "Fernandez-Gonzalo" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Critical Care Center, Parc Taulí Hospital Universitari, Institut d’Investigació i Innovació Parc Taulí-I3PT, Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Caracterización y abordaje de las alteraciones cognitivas y emocionales en el paciente crítico COVID-19 al alta de UCI" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In the viewpoint article “Psychiatry and COVID-19” published in the <span class="elsevierStyleItalic">JAMA</span> journal, Öngür et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> highlight the impact of the COVID-19 pandemic on the mental health of SARS-CoV-2 infected patients, the general population, health care professionals and vulnerable people with major psychiatric disorders.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Focusing in COVID-19 patients, is known that SARS-CoV-2 infection affects both the peripheral and the central nervous systems and is associated with a broad spectrum of neurological syndromes.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Although rates of psychiatric morbidity associated with COVID-19-related brain dysfunction remain unknown, early reports suggest that non-critical SARS-CoV-2 patients suffer from attention deficits, processing speed difficulties and anomia after overcoming the disease. COVID-19 patients admitted in the Intensive Care Unit (ICU) can be particularly vulnerable to develop Post-Intensive Care Syndrome (PICS). Thus, cognitive impairment is another challenge that must be addressed in COVID-19 post-ICU patients, particularly in those of working age.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Critical illness itself and its management can generate a burden of sequelae related to PICS, which includes cognitive impairment and emotional disturbances during the weeks and months following ICU discharge. Recent findings reveal three different phenotypes of cognitive status one month after ICU discharge in patients who underwent mechanical ventilation (MV) and suggest the existence of different brain-dysfunction patterns in ICU survivors. Specifically, 47% of patients presented moderate-to-severe cognitive deficits, with executive functions, processing speed and memory being the most altered cognitive domains.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Critically ill COVID-19 patients requiring prolonged MV are prone to develop delirium during ICU stay, which is also a robust precipitating factor for long-term cognitive impairment in critical non-COVID-19 patients.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Furthermore, most hospitals caring for critically ill patients with COVID-19 have been forced to adopt emergency measures, disrupting the routine management of ICU patients. Prohibition of family visits, isolation to prevent further spread of the disease and changes in the nurse/patient ratio are some of the restrictions that may hinder recovery from delirium and increase mental health problems in COVID-19 post-ICU patients.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Beyond the cognitive impairment associated with COVID-19 critical illness, stress, anxiety and depression may <span class="elsevierStyleItalic">per se</span> worsen the cognitive function of ICU survivors. Therefore, the characterization of cognitive phenotypes in COVID-19 ICU survivors, and the establishment of protocols to address PICS-related cognitive impairment are of the utmost interest.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In agreement with Öngür et al., <a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> during the pandemic we have incorporated different tools for monitoring patients in a non-presential and continuous way throughout their recovery process after ICU discharge. Patients perceive these resources as facilitators for recovery, whereas clinicians trace patient's evolution and obtain a valuable follow-up data that allows a quick detection of alterations, and the implementation of early tailored interventions. Furthermore, the incorporation of innovative digital therapies aimed at providing cognitive stimulation during the ICU stay<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> could also be considered a viable and safe alternative to prevent the cognitive and emotional alterations in the COVID-19 post-ICU survivor. Therefore, what we have learned from the pandemic is that ICU extended support based in telemedicine and digital therapies have come to stay.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0035" class="elsevierStylePara elsevierViewall">The work was supported by the Instituto de Salud Carlos III (grant COV20/00595 of the Convocatoria extraordinaria para la investigación sobre el SARS-CoV-2 y la enfermedad COVID19, con cargo al Fondo-COVID19, Ministerio de Ciencia e Innovación, Gobierno de España).</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Psychiatry COVID-19" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D. 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Bharucha" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/brain/awaa240" "Revista" => array:6 [ "tituloSerie" => "Brain" "fecha" => "2020" "volumen" => "143" "paginaInicial" => "3104" "paginaFinal" => "3120" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32637987" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cognitive phenotypes 1 month after ICU discharge in mechanically ventilated patients: a prospective observational cohort study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Fernández-Gonzalo" 1 => "G. Navarra-Ventura" 2 => "N. Bacardit" 3 => "G. Gomà Fernández" 4 => "C. de Haro" 5 => "C. Subirà" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/s13054-020-03334-2" "Revista" => array:5 [ "tituloSerie" => "Crit Care" "fecha" => "2020" "volumen" => "24" "paginaInicial" => "618" "itemHostRev" => array:3 [ "pii" => "S0002870314006012" "estado" => "S300" "issn" => "00028703" ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Delirium as a predictor of long-term cognitive impairment in survivors of critical illness" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "T.D. Girard" 1 => "J.C. Jackson" 2 => "P.P. Pandharipande" 3 => "B.T. Pun" 4 => "J.L. Thompson" 5 => "A.K. Shintani" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/CCM.0b013e3181e47be1" "Revista" => array:6 [ "tituloSerie" => "Crit Care Med" "fecha" => "2010" "volumen" => "38" "paginaInicial" => "1513" "paginaFinal" => "1520" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20473145" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Feasibility and safety of virtual-reality-based early neurocognitive stimulation in critically ill patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Turon" 1 => "S. Fernandez-Gonzalo" 2 => "M. Jodar" 3 => "G. Gomà" 4 => "J. Montanya" 5 => "D. Hernando" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/s13613-017-0303-4" "Revista" => array:5 [ "tituloSerie" => "Ann Intensive Care" "fecha" => "2017" "volumen" => "7" "paginaInicial" => "81" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28770543" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/02105691/0000004600000002/v1_202201270546/S0210569120303454/v1_202201270546/en/main.assets" "Apartado" => array:4 [ "identificador" => "57221" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Cartas al Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/02105691/0000004600000002/v1_202201270546/S0210569120303454/v1_202201270546/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569120303454?idApp=WMIE" ]
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