Occupational therapy’s focus on functional cognition offers a distinct approach to the assessment of and intervention for occupational performance deficits that may follow coronavirus disease 2019 (COVID-19). Although the majority of people survive COVID-19, many people experience persistent functional cognitive sequelae severe enough to interfere with occupational performance. After COVID-19, people may be categorized as either (1) those who experience severe or critical illness requiring hospitalization or (2) those with mild to moderate presentations of the virus without hospitalization. A third group of those who do not have ongoing signs of active infection but who experience new, lasting, or deteriorating symptoms has begun to emerge and may represent a distinct COVID-19 long-haul syndrome. By following the Occupational Therapy Practice Framework and using established processes for occupational therapy assessment and treatment of functional cognition, occupational therapy practitioners can tailor assessments and interventions to meet clients’ needs.
Since the onset of the coronavirus disease 2019 (COVID-19) pandemic in early 2020, medical professionals have developed interventions to address the clinical presentations of COVID-19, which vary in severity from asymptomatic infection to critical illness or death (Taquet et al., 2021). Much of the early focus has been, by necessity, dedicated to managing the acute stages of the infection, and less is known about the long-term consequences for those recovering from COVID-19. Although the impact of COVID-19 on people’s health status remains under investigation (Tenforde et al., 2020; Zhou et al., 2020), occupational therapists can lead the efforts to address occupational performance and impairments in functional cognition that may follow COVID-19. The Occupational Therapy Practice Framework: Domain and Process (4th ed. [OTPF–4]; American Occupational Therapy Association [AOTA], 2020) provides guidance for practitioners on how to screen and assess clients and how to design effective interventions to manage changes in functional cognition and occupational performance after COVID-19 (Skidmore, 2017; Wolf et al., 2019). Our discipline has the tools and must now implement them with confidence.
Scope of the Problem
At this writing, the Centers for Disease Control and Prevention (n.d.) has reported more than 33 million COVID-19 infections and 600,000 deaths in the United States. Although primarily a respiratory virus, COVID-19 affects multiple organ systems, and many symptoms suggest direct effects on the brain. In many cases, anosmia and dysgeusia may positively predict COVID-19 infection and precede the onset of respiratory symptoms (Melley et al., 2020; Romero-Gameros et al., 2020). Other neurological symptoms are common within the first few days of infection, including delirium, even among young and middle-aged adults (Helms et al., 2020). Encephalopathy, meningoencephalopathy, stroke, dementia, psychosis, and petechial hemorrhage throughout the brain have been reported (de Erausquin et al., 2021; Taquet et al., 2021).
The full impact of COVID-19 on functional cognition is unclear, yet lessons learned from other coronaviruses and respiratory conditions helped in preparing the occupational therapy profession’s response (Ahmed et al., 2020; Rogers et al., 2020). Significant evidence has indicated that severe respiratory conditions, such as acute respiratory distress syndrome (ARDS), severe acute respiratory syndrome (SARS), and Middle East respiratory syndrome (MERS), culminate in changes to functional cognition. Some people who recovered from SARS and MERS reported memory impairment, and others described persistent posttraumatic stress disorder, depression, insomnia, or anxiety disorders (Ahmed et al., 2020; Rogers et al., 2020). Delirium after ARDS, pneumonia, and sepsis have also been shown to be risk factors for long-term cognitive impairment (Herridge et al., 2011), with cognitive functions often being impaired 6 to 12 mo after intensive care unit (ICU) discharge (Girard et al., 2010; Mitchell et al., 2018; Taboada et al., 2021). The long-term effects of an ICU admission, termed postintensive care syndrome (PICS), include persistent cognitive dysfunction, and those who have experienced ICU stays as a result of COVID-19 are at risk for PICS (Heneka et al., 2020; Luetz et al., 2019). In addition, people who had a cognitive disorder (e.g., mild cognitive impairment, major neurocognitive disorder) before COVID-19 infection may have alterations or exacerbations in the presentation and course of their illness (Heneka et al., 2020; Taquet et al., 2021).
On the basis of currently available data, it is reasonable to expect that clients with severe COVID-19 infection may experience executive function deficits, memory impairment, and psychiatric difficulties during and after acute infection (Almeria et al., 2020; Rogers et al., 2020; Varatharaj et al., 2020). In addition, even more people have had COVID-19 but were not hospitalized or did not have an extended stay in the ICU, and case reports have indicated that some non-hospitalized people experience post-COVID cognitive deficits severe enough to compromise occupational performance at work several months after the initial infection (Hellmuth et al., 2021). In one case, a 33-yr-old otherwise healthy patient returned to work 114 days after symptom onset but noted difficulties in performing work-related activities that required her to adopt compensatory strategies. Neuropsychological testing performed 149 days after symptom onset revealed deficits in working memory, with disorganization, inefficiency, and error-prone performance (Hellmuth et al., 2021). These limited case series reports, along with growing anecdotal evidence, suggest that even those with mild to moderate symptoms may have persisting functional cognitive impairments. There may also be an additional category of people with COVID-19 “long-haul syndrome” who report new or worsening symptoms after recovery from the initial infection that may include functional cognitive impairments (Orrù et al., 2021).
Occupational Therapy Practitioners’ Response to Functional Cognitive Impairments
Although further work is required to fully describe the nature of the functional cognitive deficits that may follow COVID-19, occupational therapy practitioners can use the core aspects of the occupational therapy process to screen and assess for functional cognitive impairments and deliver tailored treatment approaches to clients. Early in the onset of the pandemic, occupational therapy practitioners reported that clients with COVID-19 experienced a variety of cognitive deficits that were often detected through the routine process of conducting an occupational profile or performing a task analysis. Practitioners reported that clients presented with confusion, slower processing, executive function difficulties, impaired safety awareness, and short-term memory impairments, and they often lacked insight into the nature of their difficulties. Clients shared with occupational therapy practitioners that they felt “off” when performing functional tasks or that they experienced brain fog and were shocked by the time needed to complete simple tasks.
Currently available screening and assessment techniques will likely identify the majority of clients who have functional cognitive impairments. However, practitioners should also be sensitive to clients’ self-reports of new cognition-related concerns with instrumental activities of daily living (IADLs; Lange et al., 2019; Schmitter-Edgecombe et al., 2011; Theadom et al., 2018; Yam & Marsiske, 2013). In addition, occupational therapy practitioners working with clients recovering from COVID-19 should ensure that clients understand not only the potential physical manifestations of COVID-19 but also the functional cognitive sequelae of the illness. Occupational therapy practitioners can respond to clients with post–COVID-19 impairments using previously established practice frameworks that support functional cognition (AOTA, 2019; Wolf et al., 2019).
Functional Cognitive Assessment
When assessing functional cognition, occupational therapy practitioners must determine how occupational performance might change as a result of alterations in cognitive processes. The OTPF–4 (AOTA, 2020) and the Cognitive Function Evaluation–Extended (Bar-Haim Erez & Katz, 2018) provide a systematic approach to assessing functional cognition (Wolf et al., 2019). Essential to this process is completing an occupational profile, selecting meaningful occupation-based goals (i.e., using the Canadian Occupational Performance Measure [COPM]; Law et al., 2019), and completing assessments to identify breakdowns in performance skills or patterns during occupational performance. Some acute care and rehabilitation departments use quick screening tools such as the Brief Interview of Mental Status (Saliba et al., 2012), the Montreal Cognitive Assessment (Nasreddine et al., 2005), or the Saint Louis University Mental Status exam (Tariq et al., 2006). Although these tools are helpful in screening for global cognitive impairment, they do not evaluate the capacity to perform complex daily activities, which are dependent on the interaction among the person, environment, and task demands.
To best describe and document functional cognitive changes, clients must complete standardized performance-based measures, such as the Executive Function Performance Test (Baum et al., 2008), Performance Assessment of Self-care Skills (Holm & Rogers, 2008), Weekly Calendar Planning Activity (Toglia, 2015), and Kettle Test (Hartman-Maeir et al., 2009), or therapist-constructed tasks to assess breakdowns in performance skills during cognitively complex IADLs such as cooking, medication, and money management (Fisher & Marterella, 2019). Because functional cognitive deficits can limit a person’s ability to notice and respond effectively to errors during performance, exacerbate motor dysfunction, and increase safety risk, best practice indicates that performance-based assessments should be used to document how cognitive impairments such as brain fog, decreased short-term memory, or executive function may interfere with the performance of real-life occupations. In addition, using goal-focused tools such as the COPM allows occupational therapy practitioners to track changes clients experience related to their perspective on overall performance quality of and satisfaction with selected occupations.
Interventions for Functional Cognition
Occupational therapy practitioners have a range of established intervention options to select from to create effective plans of care to specifically address changes in performance patterns and cognitive capacity after COVID-19 (AOTA, 2019). Clients with severe impairments may be unaware that cognitive challenges exist and will be more likely to benefit from intervention approaches focused on task and habit training or care partner training and environmental modifications based on the Cognitive Disabilities Model (Levy, 2018). For community-dwelling older adults with dementia, social contact and cognitive stimulation were extremely limited during periods of the pandemic, potentially exacerbating psychiatric and behavioral disorders and increasing care partner stress (Cagnin et al., 2020; Rainero et al., 2021). Occupational therapy practitioners can provide family members with strategies to support and supervise people who have signs of confusion, poor judgment, and impaired awareness to maximize safety and independence after discharge (Gitlin et al., 2018; Gitlin & Corcoran, 2005).
Clients with more awareness of their cognitive challenges and who demonstrate the ability to learn new information will benefit from interventions that reinforce learning strategies to overcome their performance problems. Strategy training supports more long-term improvements in occupational performance as clients learn to generalize these strategies to new and different functional activities (Skidmore et al., 2017). Strategy training and learning approaches vary in protocols and techniques depending on which approach is being used (e.g., Dynamic Interactional Model [Toglia, 2018], Cognitive Orientation to daily Occupational Performance approach [Dawson et al., 2017]). These techniques can support people with limited awareness of difficulties to develop compensatory strategies that improve their performance of selected occupations by encouraging them to explore various ways to perform a task (Kersey et al., 2019).
Functioning in the Larger Context
When working with people with COVID-19 long-haul syndrome, occupational therapy practitioners should stay focused on supporting clients’ goals, understanding their concerns, and validating their experiences (Lancet, 2020). Occupational therapy practitioners should use interventions established for other clinical populations with functional cognitive deficits to assist post-COVID clients to learn to manage their difficulties with occupational performance. These interventions may include changes to roles and routines, self-pacing, and self-monitoring strategies. With support, clients can appropriately modulate their expectations for the recovery process (e.g., monitor pacing during tasks, take more regular rest breaks to accommodate to the changes to their respiratory system, avoid making complex decisions when fatigued, recognize signs of short-term memory problems that may limit performance of previously routine tasks, and encourage use of strategies such as note taking). Occupational therapy practitioners should also address the psychosocial issues that surround isolation, confusion about the nature of the disorder, and worry about potential stigma that may be associated with a COVID-19 diagnosis.
Occupational therapy practitioners must work within the existing systems of care and with other professionals to ensure that people seeking rehabilitation services who have any symptoms related to COVID-19 are referred to occupational therapy for functional cognitive screening. Some clients may not attribute the changes in their performance they experience to cognitive deficits and may not ascribe these deficits to COVID-19. Health systems should ensure that therapy practitioners are provided with appropriate in-service training to adequately respond to the needs of clients who have had COVID-19.
The current literature on the connection between cognition and COVID-19 is limited, yet evidence from prior coronavirus epidemics and ARDS suggests that many people will experience functional cognitive and occupational performance deficits. Fully understanding the potential symptom manifestations of postacute COVID-19 will be vital to the provision of long-term, evidence-based care for clients recovering from infection (Amenta et al., 2020). The construct of functional cognition has deep roots in the profession of occupational therapy and incorporates theoretical and procedural refinements that offer some distinct advantages in terms of intervention selection (Barco et al., 2019). Occupational therapy practitioners should carefully assess the occupational performance of post–COVID-19 clients to identify breakdowns in functional cognition as an essential part of the comprehensive evaluation and monitoring phase. Although the occupational performance deficits that may follow COVID-19 remain in many respects uncharted territory, occupational therapy practitioners can use the established approaches developed for use with other populations to detect and manage the breakdowns in occupational performance occurring in the COVID-19 population.
We thank the occupational therapists we interviewed regarding occupational therapists’ response to deficits in functional cognition associated with COVID-19 infection: Caitlin Cronin, Marissa Dastice, Jackie Dusing, Erin Mangin, Samantha Panighetti, Courtney Smith, and Madeline Williamson.