In the early months of the pandemic, much of the research on COVID-19 focused on the manner in which the disease affected respiratory function, i.e., the capacity to breathe.  Over the course of the last seven months, as more data has become available, it has become clear that COVID-19 adversely affects cognition (including capacity to pay attention, remember information, speak and multitask)  and emotional state (including risk of depression and anxiety).

So how can SNF management identify patients whose mental health is adversely affected by COVID-19 and create a plan of care to assist them?

To address the issue, Executive Mental Health clinical neuropsychologists Dylan Harwood, Ph.D., Po-Haong Lu, Psy.D., Earl C. Thorndyke III, Ph.D., Jennifer Geren, Ph.D., and Alexander J. Steiner, Psy.D., considered emerging scientific findings and expert medical opinions on the impact of coronavirus on mental health functioning, feedback from partner facilities and data obtained from the evaluations of residents/patients at those facilities. 

What is the medical community saying about the effect of coronavirus on the brain?

In a relatively short period of time, various researchers and clinicians have established that COVID-19 is likely to have an adverse effect on the brain. For example, the July 21 edition of UptoDate explains over 50% of hospitalized COVID-19 patients present neurologic complications, including but not limited to: headache, dizziness, myalgia, alteration of consciousness, disorders of smell and taste, weakness, strokes and seizures. These neurological manifestations appear more severe among critically ill patients.

Other relevant studies appearing in JAMA Neurology, NEJM, Neurology, Neurology Today, Brain and Annals of Clinical and Translational Neurology document that the effects of COVID-19 on mental health are of concern, and there does not appear to be a specific timeline for the emergence of neurological symptoms, as they can occur when a patient is hospitalized or weeks after infection.

What are skilled nursing facilities telling us?

Geren and Steiner tapped into long-standing relationships with facilities to develop a deeper understanding of their experiences and to highlight the high level of concern facility management are experiencing.

“Without a doubt, facility management is concerned and worried about their residents’ health, and at times is overwhelmed with the many challenges they face,” Geren said. “There is great concern that patients with dementia in particular have been declining more rapidly due to the loss of face-to-face contact with family members who would previously visit on a regular basis. Limitations on group activities and socialization is impacting residents across the board, but again dementia patients appear to be suffering more as they rely on external/environmental stimulation for wellbeing.”

The clinicians also detected a notable deterioration in the mental health of patients afflicted with coronavirus.

“Our neuropsychologists are receiving more reports of staff members’ concern for their residents’ emotional well-being compared to physical health matters since the onset of the pandemic,” Steiner noted. “Even patients who have not received a positive diagnosis can experience significant adverse symptoms characteristic of anxiety, depression, stress and phobia in response to either the possibility of acquiring COVID-19 or the restrictions and logistical challenges that have been implemented since the start of the pandemic.”

Many cases of COVID-19, even in SNF settings, are asymptomatic. In addition, the staff at SNFs aim to support the mental health of all residents, regardless of whether the residents have contracted COVID-19.

“SNF staff are finding creative ways to keep residents engaged and connected,” Geren said.

“They facilitate FaceTime calls with family, create bubble rooms for plexiglass visits, host socially distanced recreational activities and provide individualized activities at the bedside.” 

Neuropsychology assessments pre- and post-COVID-19

Typically requested by the facility social services director or the director of nursing, neuropsychological assessments traditionally enable staff to formulate a differential diagnosis on behalf of the patient, offer prognoses and assist in creating treatment plans, track response to treatment and/or recovery from an acute illness, evaluate the patient’s capacity for making independent healthcare and financial decisions and more.

Since the onset of the pandemic, the utility of neuropsychological assessment has become increasingly integral to the provision of comprehensive mental healthcare in the SNF setting based on the following reasons:

  • SNF residents are more likely to be older and/or afflicted with multiple medical morbidities;
  • SNF residents have a greater likelihood of onset of depression or other mood disorders as a consequence of social distancing and isolation; and
  • SNF residents have increased risk of cognitive deficits, both directly as a consequence of COVID-19 exposure or indirectly as a consequence of other medical or mental state conditions arising from situational factors, such as social isolation.

Next steps for SNFs

As neuropsychology support is even more essential for patients who are at high risk of contracting coronavirus or have emerged from COVID-19, SNF management can respond by:

  1. Carrying out baseline cognitive assessments.

Given the risk of cognitive decline resulting from COVID-19 infection and related care or complications (e.g. prolonged hospitalization, intubation, sedation, stroke, etc.), having a baseline assessment of residents’ neuropsychological functioning is key. This critical information will enable staff to determine the impact of the illness, track the patient’s recovery and characterize any persistent or long-term effects.

 2. Monitoring patients closely for changes in mental status.

Consider a review of your resident’s level of alertness, disorientation or any other notable deviations from a patient’s usual presentation. Alterations in mental status can be signs of the onset of illness, and sensitivity to these changes in mental state can be used as a catalyst for facility staff to obtain the needed care on behalf of the resident. 

3. Reaching out for referrals.

For those patients returning to a SNF from acute care related to COVID-19 infection, early referral to neuropsychology is important. Neuropsychological assessment is needed to establish the patient’s current level of functioning so that tailored recommendations can be made for the patient’s care in the near term. Early assessment will also allow for better detection of improvements or changes that may occur over time.

4. Evaluating mood symptoms post COVID-19.

Neuropsychological assessments also examine the patient’s mood symptoms and psychological stress that may follow COVID-19 illness and treatment. These mood symptoms can also impact cognition, thus making the need for comprehensive testing critical for understanding the patient’s needs and assisting in their recovery.

5. Not waiting. With all the associated stressors arising during the current pandemic, the time to act is now. Being proactive and reaching out to all medical professionals, including neuropsychologists, will help reduce the clinical workload, reduce morbidity by identifying at-risk patients and support the creation of customized care plans.

Ari Kalechstein, Ph.D., is president and CEO of  Executive Mental Health and offers 24 years of experience as a licensed psychologist in California and Nevada. His areas of expertise include all aspects of geropsychology, forensic work and addiction.