What is the treatment for post-COVID (Coronavirus disease 2019) brain fog?

Treatment for Post-COVID Brain Fog

For post-COVID brain fog, a comprehensive approach including cognitive rehabilitation, psychological support, and symptom-targeted interventions is recommended, with exercise carefully managed to avoid worsening symptoms in those with post-exertional malaise. 1, 2

Understanding Post-COVID Brain Fog

Brain fog in long COVID is characterized by:

• Memory impairment
• Word-finding difficulties
• Difficulty concentrating
• Mental fatigue
• Often accompanied by fatigue, dizziness, and myalgia 3

First-Line Interventions

Cognitive Rehabilitation

• Neuropsychological treatment and cognitive stimulation (45 minutes daily sessions) have shown significant improvement in cognitive function 4
• Focus on attention tasks, abstract reasoning, language repetition, memory recall, orientation, and visuospatial abilities

Mental Health Support

• Psychological counseling and mental health education
• Non-drug treatments:
  • Mindfulness training
  • Breathing relaxation techniques
  • Cognitive behavioral therapy
  • Group interventions 1, 2

Physical Activity Management

• Important caution: Exercise is harmful for patients with post-exertional malaise and should not be used as treatment; 75% of patients report worsening with physical activity 1
• For those without post-exertional malaise:
  • Resume activities at a conservative, safe pace
  • Increase exercise gradually based on symptoms
  • Consider gentle traditional exercises like Tai Chi or Baduanjin 1, 2

Promising Interventions

Emerging Treatments

• Noninvasive brain stimulation has shown improvement in cognitive ability 5
• Hyperbaric oxygen therapy has demonstrated improvements in cognitive assessment tests and brain perfusion 5
• Palmitoylethanolamide and Luteolin (PEA-LUT) supplementation has shown benefits for cognitive impairment 5

Anticoagulant Therapy

• Triple anticoagulant therapy has shown promise in resolving symptoms in small studies, potentially by addressing abnormal clotting 1
• Apheresis may help remove microclots but is expensive with uncertain benefits 1

Supplements

• Coenzyme Q10 and D-ribose have shown promise for fatigue symptoms 1

Lifestyle Modifications

Sleep Management

• Poor sleep quality correlates with brain fog symptoms 6
• Implement sleep hygiene practices and address sleep disorders

Gastrointestinal Health

• Gastrointestinal symptoms are significant predictors of brain fog severity 6
• Consider traditional herbs with "regulating stomach and dissipating dampness" effects for digestive symptoms 1

Treatment Algorithm

1. Assessment: Screen for post-exertional malaise first
2. If post-exertional malaise present: Implement pacing strategies, avoid exercise
3. If no post-exertional malaise: Gradually introduce gentle physical activity
4. For all patients:
   • Implement cognitive rehabilitation
   • Provide psychological support
   • Consider promising interventions based on availability and patient preference
   • Address sleep and gastrointestinal issues

Clinical Pitfalls to Avoid

• Do not recommend exercise for patients with post-exertional malaise (75% worsen with physical activity) 1
• Avoid dismissing symptoms as purely psychological; brain fog in long COVID has demonstrable physical correlates 3
• Don't overlook the importance of addressing comorbid symptoms like fatigue, dizziness, and myalgia that often accompany brain fog 3
• Be aware that brain fog symptoms may be worse in women and those with COVID-19 reinfections 6