NEUROLOGOCAL MANIFESTATIONS OF COVID-19

Interviews

This is a time of a pandemic, a time when everyone is worried about the third wave. The second wave is over but what about those who are suffering from long term covid effect? It’s a very stressful time for anyone as it is but for those who have underlying neurological conditions, those who are suffering from some brain fog post covid? What about them? What should they do should? Should they get vaccinated or not? What are the symptoms they should watch out for? Should they continue with their physiotherapy?

To discuss the same we had a panel of experts: Dr. JD Mukherjee, Director of Neurology, Max hospital; Dr. Rajneesh Kumar, Senior Consultant, Neurology Paras Hospital; Dr. PN Renjen Senior Consultant, Apollo Hospital.

What exactly is brain fog? Can covid trigger it to begin with?

Dr JD Mukherjee: Brain fog is not a disease or a disorder well known. It’s not a very well defined condition, but it’s a conglomeration of symptoms that include a general feeling of fatigue, cognitive inefficiencies like inability to concentrate and inability to focus. The customary speed of clarity of thoughts when doing cognitive functions. So it’s like you know when somebody has alcohol withdrawal or alcohol over or jet lag, confused, working fast or not able to concentrate, that combination of symptoms is what is called brain fog. It’s a general term and it is super specific. What is being noticed is that a lot of post-covid status. A lot of patients suffer from this. Now there can be various reasons for this that we can discuss as we go on, but this is the broad outline definition of what is brain fog. The major symptom of this is basically not being able to think properly, not being able to concentrate, not focus, not being able to type and not being able to do things at the speed with which we need to.

How are they able to even recognise their symptoms? And What are they supposed to do next? Should they visit a neurologist? Should they go to a hospital?

Dr JD Mukherjee: So, anyone who has these problems should definitely consult a doctor. They don’t have to rush to the neurologist and the doctor can clinically examine them and see if these symptoms require a neurologist. Does it require a CT scan or an MRI or any other blood test? So I am sure any doctor would be able to adjudicate that this requires this and this investigation does not require this. There will be a lot of overlay and overlap between anxiety, depression, confusion, dementia, all these features. There will be an overlay and overlap of symptoms in a patient with brain problems. For each needs to be ruled out. As you know, in Covid, any patient can have anticlastic pictures, and can have strokes, so all these need to be excluded before we call it a brain problem.

How does covid affect the brain? How are people to understand that?

Dr PN Renjen: The brain fog phenomenon is more common in the elderly than in younger individuals. You got to make sure whether your patient already had an underlying memory disturbance or he had an underlying dementia which has now become precipitated in the post-covid period. Sometimes you really don’t know whether these drugs themselves are causing their confusion. If a patient has any chance of seizures in the period of covid and if he is on this drug, they very often develop higher mental function disturbances.

How long does these covid related neurological symptoms, and if we talk specifically about brain fog, how long does it last? Can it have a lifelong or a long lasting effect or is there something which patients can do to manage the same?  

Dr Rajnish Kumar: There are a number of causes of brain fog. We need to look at the reason behind it and then we need to work. Many of the cases may be because of depression and anxiety and fatigue, which is happening because of the disease. So you need to basically help the patient in the sense that we need to motivate them a little bit, like by doing aerobic exercises. It has been seen that it’s a very good way to really help the patient, so you can start with small exercises of five to 10 minute duration. Slowly, you need to increase it and as you increase it, you will find that exercises also help with your memory and retention, so that’s going to help us in this condition, and the best way to do it is about 35 minutes of exercises 5 times a week. If you start and you slowly do those things, you find that a person slowly starts to come in their normal sense. A diet rich in antioxidants is very important. Fruits, vegetables, and dry fruits are very important because they can help us to come out of this condition. Thirdly, I’ve seen that socialising helps out a lot, because all this time we have been living in our own homes, interactions have only been digital interactions. As much as social interaction increases, a number of people will recover from this condition because it also gives comfort to our lives. People have also seen that sleep is very important because if you have good sleep, it also helps out because good sleep is something which helps our body systems’ immune systems to come up and that is another way it is going to help with this condition. It’s basically an overall condition that we need to assess and treat accordingly.

Are there any medications at all for the same?  

Dr JD Mukherjee: So there is no specific medication for anti-brain fog medicine. As such, you have to find out if there is an underlying cause, like if there is a seizure going on or if there is a stroke going on, then you have to treat it separately and specifically for that, but as for general brain fog, all you need to know is to tell the patient to sleep well, rest well, and eat adequately.

When you have covid you are completely isolated for children its furthermore for parents have to take care of children who aren’t going outdoors at all elderly everyone completely locked up in the house no social life also if you get covid back in the second wave there was a high fear of mobility and reports coming in of no bed availability. How is a person supposed to manage their health in a situation like that?

Dr PN Renjen: Exactly again, see that the food brain fog in the elderly would ideally be different from the situation in children. Why do I say that? Because what may be interpreted as a brain fog could be anxiety, depression, staying in the house, irritability, lack of concentration and lack of attachment. I think these children, the other day, I was speaking about the same thing, are not getting brain fog in the true sense. If you want to call brain fog a disturbance of coordination, a disturbance of confusion in children, I think it is bold man adjustment to the situation that they are in and regarding the treatment. I don’t give them anything. If they are restless, I may give them something. I’ve done a lot of patients or minors have done MRI’s. I found nothing in them. I have done EGS. I found nothing to really speak of. What I tell them is to take good hydration, take some antioxidants, restless lack of sleep, and give some mild solutions. Otherwise, don’t treat them as you will be making them worse with your treatment.

A lot of elderly have Parkinson’s, some have Alzheimer’s how are there to take care of themselves? And any tips for caretakers many of them are totally bedridden and they need someone to physically be with them and take care of them what happens if they get covid and what the general tip you would like to give a caregiver who is taking care of an elderly perhaps who has a Parkinson’s disease or other such severe neurological issue?

Dr Rajnish Kumar: If you see Parkinson’s or if you see Alzheimer’s, you know that caregivers are also too space bound to look into the things that do not express themselves, especially in Alzheimer’s people. Because they do not have any insights, it becomes a very big problem to support them. You have a number of small groups where the patients would come in the morning and they would meet and then they would go. Earlier in the pre-covid era, you had those types of facilities. Small facilities were there, but they were also closed down during this period of time. We also found out that many of my patients suffered a lot and the caregivers also suffered a lot. The number of my caregivers who had migraines increased, who had headaches for tension headaches had increased. So what we did from our hospital was have a small zoom meeting of the caregivers that would bring it out. If you could hear the patients, we were trying to do that out, because the more you talk about if they can express themselves, you can really just give them small directions that really help out a lot in this condition. For medications, we do not have a lot of medications. We do not need to change a lot of medications, but you need to have support, which is very essential.

Can we or should we continue medication? Should a patient suffering from neurological issue continue with their normal medication over and above you know the covid steroids rather medicine which they may be consuming?

That’s a very pertinent question that you asked, so let me answer it in sub-groups. So, supposedly, if somebody has a pre-existing medication, for example, for epilepsy or Parkinson’s disease, they should continue with the medication. What happens is that the level of care drops, particularly if it is an isolated ward or isolated at home. The level of care drops tremendously and patients are stuck on these medications. So all efforts must be made to continue with the medications. Coming to our specific question about stroke and covid, we have to see what type of stroke it is. It’s an emerging stroke. We can’t continue with asking that and vice versa. If there is a haemorrhage for some other reasons, we can’t get it as space, but if it’s an estimated stroke, I don’t see any reason why we can’t give aspirin, but if there is an extreme stroke, I don’t see any reason why we can’t give aspirin. You may sometimes have to increase the dosage of medication. For example, somebody’s got inversely, we have to increase the growth of certain patients. Certain patients require increased scaling of the strike. Patients require scaling up the requirements for Parkinson’s, so every patient will be dealt with differently. There can not be one rule. The general principle is to continue with the treatment that you were having pre-covid and, if required, the dosage can be adjusted, escalated or scaled down depending on the response of the drug in the patient. 

Earlier during the first wave we received a lot of stroke cases post covid. Why does that happen? Anything which patients can do to avoid it? what would you suggest for someone who perhaps has recovered from covid goes home feels their okay and suddenly you know gets a stroke or some sort of numbness in their face hands etc?

Dr JD Mukherjee: The relationship between stroke and covid can be two-fold. One, I have had several patients who presented with and when you did the covid test they were covid positive, so they went to the covid ward. Another situation is that a frank covid with a lung lesion in the hospital develops a stroke. The treatment of stroke, whether you talk about political therapy where you talk about traumpactumy, has not changed in the covid area except we have laid down new guidelines for that and I was on an international panel where we loaded up all the stroke care during the COVID-19 pandemic, which was an international expert panel and we reviewed it in 2001 March April where they gave them strict guidelines. Now why do I say that? Because the pathophysiology of stroke in covid is not that simple. What does video do? Covid acts on receptors. It causes hyper stage, it causes endothelial damage and it causes artery to artery embolization. There are ten different mechanisms where covid causes a stroke, and the most interesting part where I was interested is that have you been able to demonstrate the virus in the brain to say that there is a one to one correlation between covid and stroke, which has been done in a pathological study in France. So yes, there is a direct relationship, so you got to be slightly careful when you choose your drugs. Say, for example, you have a patient who’s got an irregular heart. That’s called an AA tribulation. If he’s got a bleeding disorder, obviously you would not give him because he could die. So these day to-day changes to the way covid works are required and over a period of time we have seen all of this.

Are there any neurological condition which itself can get triggered due to covid? Could you please elaborate on that a little bit?

Dr JD Mukherjee: As we have already discussed, all neurological conditions can be exacerbated during covid pr post covid everywhere because of the stress and strain and because of the peculiar situations in which the particular pathophysiology which happens in the brain. For example, strokes can happen again in a person who has already had strokes. Parkinsonism can only worsen because of the direct effects of the disease or because of the lack of medication. One which can worsen and cause respiratory failure.