Cognitive and psychological recovery patterns across different care pathways 12 months after hospitalization for COVID-19: A multicenter cohort study (CO-FLOW)

Abstract

Background: The comparison of recovery patterns for different care pathways following COVID-19 is necessary for optimizing rehabilitation strategies.

Objectives: To evaluate cognitive and psychological outcomes across different care pathways up to 12 months after hospitalization for COVID-19.

Methods: CO-FLOW is an ongoing multicenter prospective cohort study with assessments at 3, 6, and 12 months after hospitalization for COVID-19. The main outcomes are cognitive deficits (Montreal Cognitive Assessment, score <26), cognitive failure (Cognitive Failure Questionnaire, score >43), posttraumatic stress disorder (PTSD; Impact of Event Scale-Revised, score ≥33), and anxiety and depression (Hospital Anxiety and Depression Scale, subscale score ≥11).

Results: In total, data from 617 participants were analyzed. Mean age was 59.7 (SD 11.4) years and 188 (31%) were female. Significant recovery occurred within the first 6 months post-discharge (p ≤ 0.001). Cognitive deficits persisted in 21% (101/474), and psychological problems in 15% (74/482) of people at 12 months. Significantly improved cognition scores were reported for people who did not receive rehabilitation ('No-rehab'; 124/617, 20%; mean difference, MD 2.32, 95% CI 1.47 to 3.17; p<0.001), those who received community-based rehabilitation ('Com-rehab'; 327/617, 53%; MD 1.27, 95% CI 0.77 to 1.78; p<0.001), and those who received medical rehabilitation ('Med-rehab'; 86/617, 14%; MD 1.63, 95% CI 0.17 to 3.10; p = 0.029). Med-rehab participants experienced more cognitive failure from 3 to 6 months (MD 4.24, 95% 1.63 to 6.84; p = 0.001). Com-rehab showed recovery for PTSD (MD -2.43, 95% -3.50 to -1.37; p<0.001), anxiety (MD -0.67, 95% -1.02 to -0.32; p<0.001), and depression (MD -0.60, 95% -0.96 to -0.25; p<0.001), but symptoms persisted at 12 months.

Conclusions: Survivors of COVID-19 showed cognitive and psychological recovery, especially within the first 6 months after hospitalization. Most persistent problems were related to cognitive functioning at 12 months. Recovery differed rehabilitation settings. Additional cognitive or psychological support might be warranted in people who medical or community-based rehabilitation.

Keywords: Anxiety; COVID-19; Cognition; Depression; PTSD; Rehabilitation.

Fig. 1

Flowchart of the CO-FLOW study recruitment and data gathering process. In the current analysis, 617 participants who had at least one outcome of interest were included and were assessed at 3, 6, and 12 months after hospitalization for COVID-19. >3 M, participants included after 3 months after hospital discharge; ≤3 M, participants included within 3 months of hospital discharge; CFQ, Cognitive Failure Questionnaire; HADS-A, Hospital Anxiety and Depression Scale - Anxiety subscale; HADS-D, Hospital Anxiety and Depression Scale - Depression subscale, IES-R, Impact of Event Scale-Revised; MoCA, Montreal Cognitive Assessment; M, Months.

Fig. 2

Graph showing the percentage (shown on the y-axis) of 617 participants from the CO-FLOW study with one or more deviant outcome scores (shown on the x-axis) at 3, 6, and 12 months after hospitalization for COVID-19. CFQ, Cognitive Failure Questionnaire, a score >43 indicates cognitive failure; HADS-A, Hospital Anxiety and Depression Scale - Anxiety subscale, a score ≥11 indicates anxiety; HADS-D, Hospital Anxiety and Depression Scale - Depression subscale, a score ≥11 indicates depression; IES-R, Impact of Event Scale-Revised, a score IES-R ≥33 indicates a diagnosis of posttraumatic stress disorder (PTSD); MoCA, Montreal Cognitive Assessment, a score <26 indicates cognitive deficits.

Fig. 3

Graphs showing the estimated mean Montreal Cognitive Assessment (MoCA) scores of 617 participants scores at 3, 6, and 12 months (x-axis) after hospitalization for COVID-19. Data were grouped by the 4 different care pathways as part of the CO-FLOW study. Participant MoCA score is shown along the y-axis; the dotted line at 26 refers to the MoCA score below which a cognitive deficit is indicated. In (A) the mean MoCA scores for all 617 participants in each care pathway group are shown; when participants had a MoCA score of ≥26, this score was re-used as their score for subsequent time points. The MoCA was only repeated at the next visit if the score was <26. In (B) the mean MoCA scores are presented only for those participants in each care pathway group who scored <26 at 3 and/or 6 months, to show their improvement over time. Means are adjusted for age at admission, sex, body mass index at admission, pre-COVID employment status, and length of hospital stay. None of these covariables were found to have contributed significantly to the model.

Fig. 4

Graphs showing the estimated mean scores of the (A) Cognitive Failure Questionnaire (CFQ); (B) Impact of Event Scale-Revised (IES-R) for identification of posttraumatic stress disorder (PTSD); (C) Hospital Anxiety and Depression Scale - Anxiety subscale (HADS-A); and (D) Hospital Anxiety and Depression Scale - Depression subscale (HADS-D) in 617 participants at 3, 6, and 12 months after hospitalization for COVID-19. Data were grouped by the 4 different care pathways as part of the CO-FLOW study. For each graph, scores above the dotted lines indicate either a mild (lower line) or significant (upper line impairment for) impairment for each outcome. CFQ, Cognitive Failure Questionnaire, a score >43 indicates cognitive failure; HADS-A, Hospital Anxiety and Depression Scale – Anxiety subscale, a score ≥8 indicates mild, a score ≥11 indicates significant anxiety; HADS-D, Hospital Anxiety and Depression Scale – Depression subscale, a score ≥8 indicates mild, a score ≥11 indicates significant depression; IES-R, Impact of Event Scale-Revised, a score ≥25 indicates mild, a score ≥33 indicates significant posttraumatic stress disorder (PTSD). Means were adjusted for participant age at admission, sex, body mass index at admission, pre-COVID employment status, and length of hospital stay. The following covariables contributed significantly to the models: for cognitive failure, age at admission (p = 0.011), sex (p<0.001), and length of hospital stay (p<0.001); for anxiety, age at admission (p = 0.042), and sex (p<0.001); for depression, sex (p = 0.047); for PTSD, age at admission (p = 0.004), and sex (p<0.001).