Faculty Bibliography

BACKGROUND:Early neurorehabilitation improves outcomes in patients with disorders of consciousness (DoC) after brain injury, but its applicability in COVID-19 is unknown. We describe our experience implementing an early neurorehabilitation protocol for patients with COVID-19-associated DoC in the intensive care unit (ICU) and evaluate factors associated with recovery. METHODS:During the initial COVID-19 surge in New York City between March 10 and May 20, 2020, faced with a disproportionately high number of ICU patients with prolonged unresponsiveness, we developed and implemented an early neurorehabilitation protocol, applying standard practices from brain injury rehabilitation care to the ICU setting. Twenty-one patients with delayed recovery of consciousness after severe COVID-19 participated in a pilot early neurorehabilitation program that included serial Coma Recovery Scale-Revised (CRS-R) assessments, multimodal treatment, and access to clinicians specializing in brain injury medicine. We retrospectively compared clinical features of patients who did and did not recover to the minimally conscious state (MCS) or better, defined as a CRS-R total score (TS) ≥ 8, before discharge. We additionally examined factors associated with best CRS-R TS, last CRS-R TS, hospital length of stay, and time on mechanical ventilation. RESULTS:Patients underwent CRS-R assessments a median of six (interquartile range [IQR] 3-10) times before discharge, beginning a median of 48 days (IQR 40-55) from admission. Twelve (57%) patients recovered to MCS after a median of 8 days (IQR 2-14) off continuous sedation; they had lower body mass index (p = 0.009), lower peak serum C-reactive protein levels (p = 0.023), higher minimum arterial partial pressure of oxygen (p = 0.028), and earlier fentanyl discontinuation (p = 0.018). CRS-R scores fluctuated over time, and the best CRS-R TS was significantly higher than the last CRS-R TS (median 8 [IQR 5-23] vs. 5 [IQR 3-18], p = 0.002). Earlier fentanyl (p = 0.001) and neuromuscular blockade (p = 0.015) discontinuation correlated with a higher last CRS-R TS. CONCLUSIONS:More than half of our cohort of patients with prolonged unresponsiveness following severe COVID-19 recovered to MCS or better before hospital discharge, achieving a clinical benchmark known to have relatively favorable long-term prognostic implications in DoC of other etiologies. Hypoxia, systemic inflammation, sedation, and neuromuscular blockade may impact diagnostic assessment and prognosis, and fluctuations in level of consciousness make serial assessments essential. Early neurorehabilitation of these patients in the ICU can be accomplished but is associated with unique challenges. Further research should evaluate factors associated with longer-term neurologic recovery and benefits of early rehabilitation in patients with severe COVID-19.

BACKGROUND:Little is known regarding long-term outcomes of patients hospitalized with COVID-19. METHODS:We conducted a prospective study of 6-month outcomes of hospitalized COVID-19 patients. Patients with new neurological complications during hospitalization who survived were propensity score-matched to COVID-19 survivors without neurological complications hospitalized during the same period. The primary 6-month outcome was multivariable ordinal analysis of the modified Rankin Scale(mRS) comparing patients with or without neurological complications. Secondary outcomes included: activities of daily living (ADLs;Barthel Index), telephone Montreal Cognitive Assessment and Neuro-QoL batteries for anxiety, depression, fatigue and sleep. RESULTS:Of 606 COVID-19 patients with neurological complications, 395 survived hospitalization and were matched to 395 controls; N = 196 neurological patients and N = 186 controls completed follow-up. Overall, 346/382 (91%) patients had at least one abnormal outcome: 56% had limited ADLs, 50% impaired cognition, 47% could not return to work and 62% scored worse than average on ≥1 Neuro-QoL scale (worse anxiety 46%, sleep 38%, fatigue 36%, and depression 25%). In multivariable analysis, patients with neurological complications had worse 6-month mRS (median 4 vs. 3 among controls, adjusted OR 1.98, 95%CI 1.23-3.48, P = 0.02), worse ADLs (aOR 0.38, 95%CI 0.29-0.74, P = 0.01) and were less likely to return to work than controls (41% versus 64%, P = 0.04). Cognitive and Neuro-QOL metrics were similar between groups. CONCLUSIONS:Abnormalities in functional outcomes, ADLs, anxiety, depression and sleep occurred in over 90% of patients 6-months after hospitalization for COVID-19. In multivariable analysis, patients with neurological complications during index hospitalization had significantly worse 6-month functional outcomes than those without.

Neuropsychiatric disturbances represent a common and uniquely challenging consequence of stroke. These disorders arise at the intersection of lesion-related brain dysfunction and psychological distress related to the event and its aftermath, making it difficult to identify what symptom is a direct physiological consequence of the stroke. Depression, anxiety, fatigue, apathy, emotionalism, and anger are the most common of these syndromes, and posttraumatic stress disorder related to the stroke event has become increasingly recognized as a relevant entity. Mania, obsessive-compulsive disorder, and psychosis are less commonly encountered but potentially highly debilitating conditions that may be underrecognized. Early identification and treatment may mitigate functional impairment and improve quality of life. Evidence-based guidelines from the general population are often relied upon to guide treatment. Further research is needed to understand and tailor treatment of these disorders in the poststroke population.

INTRODUCTION/BACKGROUND:The coronavirus disease 2019 (Covid-19) pandemic has led to challenges in provision of care, clinical assessment and communication with families. The unique considerations associated with evaluation of catastrophic brain injury and death by neurologic criteria in patients with Covid-19 infection have not been examined. METHODS:We describe the evaluation of six patients hospitalized at a health network in New York City in April 2020 who had Covid-19, were comatose and had absent brainstem reflexes. RESULTS:Four males and two females with a median age of 58.5 (IQR 47-68) were evaluated for catastrophic brain injury due to stroke and/or global anoxic injury at a median of 14 days (IQR 13-18) after admission for acute respiratory failure due to Covid-19. All patients had hypotension requiring vasopressors and had been treated with sedative/narcotic drips for ventilator dyssynchrony. Among these patients, 5 had received paralytics. Apnea testing was performed for 1 patient due to the decision to withdraw treatment (n = 2), concern for inability to tolerate testing (n = 2) and observation of spontaneous respirations (n = 1). The apnea test was aborted due to hypoxia and hypotension. After ancillary testing, death was declared in three patients based on neurologic criteria and in three patients based on cardiopulmonary criteria (after withdrawal of support (n = 2) or cardiopulmonary arrest (n = 1)). A family member was able to visit 5/6 patients prior to cardiopulmonary arrest/discontinuation of organ support. CONCLUSION/CONCLUSIONS:It is feasible to evaluate patients with catastrophic brain injury and declare brain death despite the Covid-19 pandemic, but this requires unique considerations.

Introduction: The prevalence of attention deficit hyperactivity disorder (ADHD) in older adults is estimated to be between 1.5 - 3.3 % across studies (Kooji et al, 2016). Older adults constitute a group in which ADHD is frequently underdiagnosed, undertreated, and often overlooked in both clinical practice and research. It is believed that older adults may have experienced longitudinal impact and a lifelong consequences of ADHD symptoms, in the absence of support for their problems in child- or adulthood (Michielson et al, 2015). Nadeau reported that age related cognitive changes, worsening physical health, and the lack of structure that often comes with retirement frequently tend to perpetuate symptoms of inattention (Nadeau, 2018). We present the case of an elderly man with ADHD. This will be followed by a review of the literature on ADHD in older adults.
Method(s): Case of Mr. R: We present the case of Mr. R, a 75-year old man who presented for evaluation of cognitive complaints. He reported chronic difficulties with attention and concentration, with recent worsening of focus, attention, concentration, and memory. Assessment consisted of evaluation of the patient, collateral information from his wife, brain imaging, and neuropsychological testing. His presentation was felt to be consistent with chronic untreated ADHD, now superimposed with mild cognitive changes across other domains. A trial of low dose methylphenidate was associated with marked improvement in his ability to focus, to follow conversations, and his working memory. The subjective changes were corroborated on the Montreal cognitive assessment (MOCA) which showed improvement in his scores, especially in the area of attention. Electronic searches of The Cochrane Central Register of Controlled Trials and the standard bibliographic databases PubMed, MEDLINE, EMBASE, and PsycINFO will be performed for papers which focus on ADHD in older adults. Keywords include "late life," "elderly," "aged," "senior citizen," or "geriatric" combined with the keywords "ADHD" or "attention deficit," Original research, case reports, and reviews will be included.
Result(s): Preliminary search conducted yielded five papers. Data from the included papers will be extracted. The epidemiology of ADHD in older adults will be discussed. This will be followed by a description of diagnostic assessment and diagnostic issues specific to older adults. The impact of ADHD in older adults will be outlined, which emphasis on its difference from that in the younger population. This will be followed by treatment considerations unique to older adults. Finally, the relationship between ADHD and cognitive impairment will be explored.
Conclusion(s): ADHD is frequently underdiagnosed and undertreated in older adults. Timely and accurate diagnosis followed by treatment results in significant improvement in symptoms and functionality. This research was funded by: None
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BACKGROUND:Patients who present emergently with focal neurological deficits concerning for acute ischemic stroke can be extremely challenging to diagnose and treat. Unnecessary administration of thrombolytics to potential stroke patients whose symptoms are not caused by an acute ischemic stroke-stroke mimics-may result in patient harm, although the overall risk of hemorrhagic complications among stroke mimics is low. CASE REPORT/METHODS:We present a case of a stroke mimic patient with underlying psychiatric disease who was treated with intravenous alteplase on four separate occasions in four different emergency departments in the same city. Although he did not suffer hemorrhagic complications, this case highlights the importance of rapid exchange of health information across institutions to improve diagnostic quality and safety. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Increased awareness of stroke mimics by emergency physicians may improve diagnostic safety for a subset of high-risk patients. Establishing rapid cross-institutional communication pathways that are integrated into provider's workflows to convey essential patient health information has potential to improve stroke diagnostic decision-making and thus represents an important topic for health systems research in emergency medicine.

Case Description: 32-year-old male with history of unintentional heroin overdose complicated by cardiac arrest and anoxic brain injury presenting with functional decline, mutism, catalepsy, rigidity and negativism consistent with catatonia. Marked improvement with lorazepam titration to 4 mg QID but symptoms were subsequently refractory. Eventual lysis of catatonia was achieved with electroconvulsive therapy (ECT) with improvement of Bush Francis Catatonia Rating Scale (BFCRS) from 17 to 0. 65-year-old male with cardiac arrest and anoxic brain injury presenting with mutism, rigidity, negativism, ambitendency, catalepsy. Treatment with lorazepam for 19 days produced significant functional gains and improved BFCRS from 26 to 9.
Setting(s): Acute Inpatient Rehabilitation Facility; Acute Inpatient Psychiatry Unit Patient: 32- and 65-year-old males with catatonia Assessment/Results: Two patients with catatonia following anoxic brain injury. One patient responded to lorazepam and later ECT. A second patient improved with lorazepam alone. Improvement was demonstrated by significant decrease in BFCRS scores.
Discussion(s): Catatonia, a psychomotor dysregulation disorder characterized by difficulty initiating/inhibiting behavior, can occur in the context of psychiatric or medical/neurologic illness and can be difficult to distinguish from static brain injury. Features include stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerisms, stereotypy, agitation, grimacing, echolalia and echopraxia. Standard treatment includes lorazepam, ECT, glutamate antagonists, and anticonvulsants but data is limited on best treatment approaches in the brain injury. While benzodiazepines are typically avoided in patients with brain injury due to their effects on neuroplasticity and sedating properties, and ECT has shown generally poor outcomes after anoxic injury, both can be safe and effective for select patients.
Conclusion(s): Catatonia is a potentially treatable mimic of static cognitive deficits after brain injury. Successful treatment of catatonia after anoxic brain injury can be achieved with lorazepam or ECT. Further research is needed to differentiate catatonia from brain injury-related cognitive and motor deficits for appropriate diagnosis and treatment