Loneliness, loss, and fading resilience in the tarnished golden years: languishing with loss of purpose

The isolation felt by people in quarantine can leave the average person feeling numb and emotionally languished. Recently, I provided a zoom conference on the psychological impact of the coronavirus in November 2021 from my office at Whittier Rehabilitation Hospital in Westborough, MA. It was well attended, largely by people who are psychologically minded and aware of the points I endeavored to make. My target audience was the people who were struggling and vulnerable to decreased coping during covid-19 recovery. I am unsure we hit the mark I was hoping for with the target audience.  The fallout in mental health from the coronavirus is real and it is now recognized as a public health menace among recovering adults. It is now being seen in children and adolescents with growing concern. Just like younger patients, loneliness and social isolation in older Americans are serious public health concerns putting them at risk for dementia and other serious health conditions including failure to thrive, sepsis, malnutrition, addiction, and mental illness according to a CDC report. For many individuals in quarantine, the nightly happy hour started earlier and earlier raising the specter of worsening substance abuse and addiction. The liquor stores were soon to be considered essential services and package delivery became a common source of re-supply. The impact of isolation, emotional loss, and social detachment undermines public and behavioral well-being across the life span. It is a co-occuring illness among illnesses afflicting millions. I see it in my own family as nerves are frayed now almost 2 years in – first noted in the blog post published in May, 2020 (Sefton, M.). In this fourth wave of the virus called the Omicron variant, people are tired of hearing about social distancing, mask mandates, and rising infection numbers. I see it every day.

I have worked with older clients for over 25 years first as a post doctoral fellow at Boston City Hospital – now BUMC. Long before the pandemic, my work at Whittier Rehabilitation Hospital has been to provide support and direct service to patients’ suffering from debility associated with decline in physical health along with the psychosocial needs and changes. All too often, this includes feelings of loss of control and sadness that is palpable in our short conversations. Many seniors feel invisible and the virus exacerbates these feelings. Declining health further instills the loss of purpose and amplifies the stigma of being seemingly infirm. The lack of purpose germinates from the passing of a spouse, close friends who move or have died, food and financial insecurity. It precedes a death wish and it’s associated demoralization. My mother was infected with the coronavirus in mid-April 2020 before the vaccine was introduced. She lived in the same nursing facility where I lost my 93-year old aunt in the first wave of the virus in May, 2020. My mother survived the virus but it has taken a significant toll on her physical and cognitive well-being. We were not permitted to see my mother during her illness and my aunt was alone on May 1 when she succumbed to the virus.

Trauma informed therapy refers to the critical understanding of one’s emotional history and supports the model of early traumatic experience being one underpinning of many mental health outcomes and threatened resilience later in life. These kinds of experiences have an impact on people who have had loved ones die while in lock down across the country and can engender guilt and helplessness. Often, singular front line medical staff are alone with patients who succumbed to the virus – sometimes holding the fading grip of another disappearing life. This heroic act of empathy happens without fanfare or even a moment to process its importance and acknowledgment of the person’s passing.

Hurry up: you are called to help save lives but are told to do nothing!

The man stopped breathing.His color signaled that he had only moments to live. His nurse called the code. This brought a hospital team of 

nearly 20 staff members assigned to the code blue team. Their job was to provide intervention for advanced cardiac care to return circulation and restore breathing. Every member of this team had a job to do. Starting with the scribe who kept track of everything. “Is somebody writing”? Inquired the maestro. Things like the minutes since the heart stopped and when he first received medication, when IV access was achieved, or the time he received the lifesaving shock to his heart, known as defibrillation. Her voice was sometimes shrill as she tried in vain to speak above the calamitous scene by tracking time since last dose of epinephrine, adenosine, or vasopressin or changing vital signs. Her job was essential and had to be accurate. These are high stress low frequency events that nobody enjoys. 

The code team works like an orchestra led by the maestro – sometimes a senior nurse. The maestro must be laser focused and have full knowledge of the patient’s recent medical history and all possible causes leading to this event. Maestro follows an ACLS protocol that guides the decision tree. The team had assigned jobs for CPR and back-up to the person assigned to be first on chest compressions. And there was the rescue breather, respiratory therapist, IV nurse, the runner for blood and other equipment, pharmacist, and physician – usually the maestro. For many team members, there is an intangible calling that underlies a doting sense of purpose which brings them into nursing.The less experienced team members may be second chair in this orchestra but all feel cheated when outcomes are bad. 

The man in question wanted no heroic measures taken and did not wish to be transferred to the trauma center if his heart were to stop beating. It was his advanced directive. 

 On this particular day, the nursing staff on duty watched the patient closely. His heart was being monitored for rate and rhythm. His breathing sounded scary in the early morning hours on the Saturday after Thanksgiving. The family had not been able to see the man who had been diagnosed with covid-19 following a stroke. By all reports his viral load was mild. He seemed to be getting better leaving most of us to believe he would slowly improve and one day make it home. I spent time with him that Friday assessing his language. It too had improved during his time in the unit.

 The physician on the day shift was not on the unit yet on the Saturday morning. It would be the man’s last day. He was running a low grade fever perhaps 99.8 degrees. This was lower than it had been the days prior. The man had started to show signs of improvement after being diagnosed with coronavirus shortly after being admitted to the rehabilitation hospital. He was fully vaccinated. So what happened? He went from being on the mend to not breathing in a matter of hours. This is what front line ICU nurses and doctors have been dealing with for 18 months during this pandemic. We saw very few cases of this type at our hospital. Afterall, he was in our hospital to rehab from his CVA.

 These events take a human toll and put a chink in the armour. Outcomes whittle away at job satisfaction, personal efficacy, and professional.purpose. The coronavirus was making its fourth appearance with a growing wave of breakthrough cases which had us all on edge. The man in this case was sick well before my breakthrough surprise. I became infected in mid-December and was sent home for quarantine. 

 The man was transferred to us following a significant left hemisphere stroke. He was sent for retraining to advance the  functionality of his language so he might return home. He had global aphasia but was getting better with using words and helping himself. Slowly, his receptive language was starting to make connections again. He started to understand nuance and gesture. He could make his point using the tools he was learning during therapy sessions. These are good signs in early stroke recovery and represent the plasticity in the human brain. He had become able to follow some perfunctory directions and express his basic needs, still sometimes missing the point by using jargon. This is known as the language of confusion in speech pathology circles. We have excellent speech pathology services at Whittier and I especially respect their efforts and expertise. 

He was not depressed and was working with his therapy team as much as he could. For their part, the staff is passionate when it comes to helping patients gain function. By standing, speaking, and eventually, directing their own care. 

When he was admitted, the man and his family decided that they wanted no heroic measures taken should his heart stop beating. No CPR, no intubation or breathing tube, no transport to a higher level of care such as the nearby trauma center. He was not a young man and believed he had lived a good life. His wishes. 

Remember, his breathing and respiratory drive took a rapid turn for the worse. Quickly, he went from looking bad to looking better, to looking worse. In a matter of a few hours his breathing had become more shallow. Agonal in quality. His nurse called the code. 

Agonal breathing usually signals a cardiac arrest. Nurses are trained to respond with the code cart and a dozen or more advanced cardiac rescue interventions geared toward restarting the heart and saving a life. Not the outcome last Saturday morning. His choice was very clear – no heroic measures. So staff were instructed to stand down and watch. Some staff became emotional and were consoled by senior nurses.They could do nothing but sit on their hands. 

The younger staff felt traumatized, as this was not supposed to happen. Even support personnel were watching as team members slowly backed away to hear witness. 

 His family was called and the sad news was shared. They had not said goodbye because of the mandated virus protocols. He did not yet receive the Sacrament of the Sick, as he had wanted. He was not alone and in the end, the group came together to recognize this man for the good fight he brought forth at rehab and for having the courage to know what he did not want, and for those few things he did. He died at 8:12 as he wished, without fanfare. The maestro on this day, reminded them all of this and that he lived a full life, and the scribe recorded the time. 

The domestic killing of another Gabby Petito: Send me dead flowers and I won’t forget to put roses on your grave

Gabby Petito with boyfriend Brian Laundrie on cross country trek
By all appearances Gabby was a smart and loving companion. She wanted to impart her love for Brian Laundrie and the life she hoped they would have together using social media. They were engaged to be married but this would never occur. Now she is the victim of homicide. “The loneliest time in a life is being in the wilderness in the middle of night, with a person you once loved, now killing you. “If you scream for help in the wilderness and there is no one there to hear it except your killer, was there ever really a scream?”” Personal correspondence from B.F. Gagan. New website: http://www.arrestbrianlaundrie.com for details on the $25,000 reward for finding Brian Laundrie. Details on the site. There have been at least 11 questionable tips transmitted to the FBI tip line as of October 4, 2021. The media reports keep Laundrie’s picture in the news cycle.  Just today someone reported seeing him on the Appalachian Trail where hikers go from Northern Georgia and finish at Mount Katahdin – the highest peak in Maine. Mr. Laundrie has done parts of the trail and is familiar with its isolation from society. He may feel that he can make a safe getaway while remaining off the grid. But someone recognized him today in South Carolina. Or a look alike. 
Gabby Pitito is a case study for intimate partner abuse. From the outside, we saw a beautiful couple enjoying the wonders of the American West. Social media accounts updated with regularity bringing hundred or even thousands of likes. Gabby had a gift for creating an image.  Only now have we learned the imagery was deeply flawed. Friends of the pair described Brian Laundrie as a jealous and controlling partner as described by Rose Davis, a friend of Gabby Petito.  Common among abusive partners is separating intended victims from their emotional support systems leaving them isolated and without friends and needed help. It is a common red flag in most cases of domestic abuse and more commonly, domestic violence homicide. In most cases the abuser has an underlying pathological jealousy and in some cases, delusions of his partner “hooking up” with someone whenever she is out of his site. Once while on duty with the police agency for whom I served, a jealous husband came crashing into town hall hoping to catch his wife in a tawdry affair while she stood in line to cast her vote in a 2015 election. He had been sending her text messages from the parking lot like “Where are you? Who are you with?” Ultimately, the man needed an escort out of the building and was given a trespass warning. For her part, she felt pangs of guilt, resentment, and fear for keeping him waiting. Shortly after Election Day the family moved away from town. It happens all the time. 
“You can’t say that nothing can be done, because nothing will be done,” said Michael Sefton, a former Westbrook police officer who now works in Massachusetts and retired from the the New Braintree Police Department.
Women are kept from seeing friends and family members in an effort to disempower them of any sense of self. We now know this got worse during the pandemic where people were isolated anyway and those living in domestic fear became further inhibited and marginalized. By outward appearance Gabby Petito was terrified of her boyfriend at the time they were stopped in Moab, UT. This behavior speaks volumes about the state of the relationship just as Supervisory Agent Melissa Hulls said after they encountered Gabby and boy friend Brian Laundrie in late August 2021. I have reached out to Supervisory Ranger Hulls on two occasions without hearing back. I am interested in hearing from few friends of Gabby Petito with their appraisal of what they saw happening to the couple during pandemic? The pair had been together over 2 years and managed to get through waves of pandemic only to be set free on the cross country junket. Both seemed physically fit and healthy. Had the pandemic and subsequent quarantine changed them in any way? How did the couple decide to embark on this journey? Whose idea was it?  “Brian has a jealousy issue,” Rose Davis of Sarasota, FL said in the September 17, 2021 New York Post article. “I’m her only friend in Florida to my knowledge and that’s not because she can’t make friends, he just didn’t want her to have friends.” Gabby Petito and Brian Laundrie at the Narrows in Zion National Park on July 18th.

Rose Davis says Gabby Petito and Brian Laundrie progressively got into “more and more arguments.”
“He was always worried she was going to leave him,” she said. “It was a constant thing to try to get us to stop hanging out.” She previously described him as a controlling and manipulative boyfriend with jealousy issues, and said Petito had sometimes stayed with her to put some space between them according to the New York Post interview with Davis. These are among the most common red flag warning for DV and DVH.

Supervisory Park Ranger Melissa Hulls
The Moab city Utah police were called to a possible case of domestic violence. The interview was caught on officer worn body camera and showed Gabby in an anxious, tearful state. Any physical signs should have been met with arrest of the likely perpetrator whether or not Gabby wanted to prosecute. The police report from Moab indicated that the officer believed something was not right! But he did not move on that feeling or was untrained as to what he might anticipate could happen next. She reported that her mental health was not good. Why? Was she in fear that the relationship was fragile and taking an unhealthy turn. Had the fuse been lit? At the very least Gabby should have been assessed for changes in her mental health and given her history, law enforcement missed the chance to understand the  underpinnings of her sudden loss of control and tearful anxiety? The care-free beginning of the exciting trip became suddenly serious enough to get on the local police department’s radar. A female national park ranger Melissa Hulls interviewed Gabby along side officers from Moab. She tried to advise Gabby that her relationship with Laundrie was had become toxic and put her in jeopardy. And just as quickly, Gabby and her fiancee fell off the police radar, leading Gabby into oblivion. Ranger Melissa Hulls saw the relationship for what it was and very likely feared for Gabby’s safety. Most murder-suicides involve intimate partners (72%) and the vast majority of these cases are women murdered by intimate partners using a firearm (Violence Policy Center, 2015). I have experience with domestic violence and the various red flag warnings of terminal anger and have tracked the downward spiral of a sick relationship. “We knew the system had failed Amy Lake” said Brian F. Gagan, a former Westbrook police officer who helped research the first psychological autopsy report, “We did not know how.” as published in the Portland Press Herald 11/30/2011. We learned plenty over the course of 200 hours of interview data and considered only confirmable facts and presented the findings to the Maine Attorney General’s Domestic Violence Homicide Review Board in the state’s Capitol. At very least, in the death of Gabby Petito, Brian Laundrie’s parents must be charged with harboring a fugitive, and aiding in the escape of a person of interest following a murder. The senior of the two responding officers in Moab is at risk of state decertification and may be charged criminally with statutory Utah failure to arrest. The officer will grope for the excuse that “neither party wished to charge” …which is not material to “Utah Mandatory Arrest”, according to Gagan. Gabby Petito’s body was found Sunday 9-20-2021 near an undeveloped camping area that’s surrounded by woodlands and brush, located about 30 miles (48 kilometers) northeast of Jackson, Wyoming. Her death was a murder according to the county medical examiner who has released very few details. Research has shown time and again that separating the couple for a “cool off” time out does little to stop domestic violence and often makes the violence increase. Meanwhile, I have seen the “neither party wants to prosecute” narrative too many times in my law enforcement career until there is serious injury to one of the partners – usually the female. I am fortunate to have never had a case go to the terminal stage of DVH, aside from Albert Flick – a Westbrook, ME case from 1979, police detectives Ron Allanach and Wayne Syphers handled while I was in the Juvenile Bureau. Flick went on to kill again, within weeks of his release from prison for killing a woman while her children looked on. The domestic victim never wants to prosecute because they have been conditioned against doing so over the years and are afraid they will be killed. Those most in fear of being killed by their partner are likely reacting to a primitive warning signal in the brain. The gift of fear  with a book by the same name highlights the subtle but powerful fear some women feel during courtship with violent men.  So, when these fears are realized, the terminal stage of violence begins the spiral downward when a domestic partner can no longer bind his angry, jealous impulses, and need for control. In spite of what the intimate partner may report to be deep felt “love” for his wife, girlfriend, and innocent family members, it comes down to murder for the sake of owning the life of a spouse and his children and feeling justified in his action. Gabby Patti’s cell phone has never been mentioned in published reports nor has her expansive social media reporting been studied. We have recommended that a safety plan be written omitting all social media whatsoever.  Everyone has a cell phone that can be tracked using triangulation data from cellular towers anywhere there is service. People who are lost can be easily found as long as cellular service is available and phones are properly charged. This is significant given her daily social media focus. It is certain the FBI has received all cell server data from both phones. This has likely contributed to the warrant issuance and national search. The cellular data was added to toll highway data from Colorado and Texas while Laundrie was on his way to Florida from the murder scene in Wyoming. It is also likely now that the Bureau is encircling his parents who may have helped him escape. At least one of them will be convinced to tell the truth because I am certain they are now being interviewed separately. They now cannot lie to protect the killer since there is now a federal warrant on him. If they do, they are then arrested and charged with being complicit in Gabby’s death. This case requires careful analysis once the murderer has been officially charged or found dead. By not doing so Gabby Petito’s death became another invisible young woman who wrongly believed she was safe and with the love of her life. After seeing the body worn police encounter, Dr. Ziv Ezra Cohen, a clinical assistant professor of psychiatry at Weill Cornell Medical College of Cornell University and staff member of New York-Presbyterian Hospital, told Fox News Laundrie and Petito were ‘both minimizing their argument’ and said the footage suggested the couple may have been high and having ‘a bad trip.’ (Fox News story). The psychologist cast doubt on the couple’s efforts to explain away the fight as caused by Petito’s OCD, insisting that the condition is ‘not a risk factor for violence.’ Petito expressed anxiety through her tears perhaps with an impending sense of doom.  ‘People with OCD are not violent. OCD is not a risk factor for violence. If there was an altercation between them, certainly OCD would not be fodder for something that would lead her to hurt him,’ according to Ezra Cohen, MD. If anything having OCD is more apt to result in being victimized and not the aggressor. Park Ranger Melissa Hills told Petito that her and Laundrie’s relationship had the markings of a ‘toxic’ one as reported in the Daily Mail.  ‘I was imploring with her to reevaluate the relationship, asking her if she was happy in the relationship with him, and basically saying this was an opportunity for her to find another path, to make a change in her life,’ added Ranger Melissa Hulls in Moab according to writer Rachel Sharp published in the Daily Mail on 9-24-2021.  Domestic Violence Fatality Review Teams identify homicides, suicides, and other deaths caused by, related to, or somehow traceable to domestic violence and review them to develop preventive interventions (Dawson, 2017; Websdale, 2010; Websdale, 2012; Websdale et al., 2017). These frequently depend on careful communication among those who work within the field of intimate partner violence including members of judiciary, bail commissioners, district attorneys, law enforcement, and social services. Without definitive recommendations, review boards provide nothing to protect potential victims and do nothing to move the needle in the direction of improved safety plans and dangerousness assessments of potential murderers. Sadly, Gabby Petito will not grow old. She will not have children or grandchildren.  She will not have a career.  It is incumbent upon society to look at the similarities among cases of domestic violence homicide using case study data, aftermath review of facts, and structured interviews to intervene ahead of the secretive pattern of control, abuse, sexual violence, and murder that happens much too often and flies below law enforcement radar. By doing so, victims build new lives with safety plans and legal contingencies for those who violate those orders of protection.

The vulnerability felt when submitting your resume: Some might call it imposter worry

I pressed click and off went my curriculum vitae for a very highly regarded position at a prestigious Boston Hospital. No chance, you might say, having read this blog for over 10 years that I might be considered for such a position. Well I am not going to lie, I did feel quite vulnerable sending my CV to a medical director site unseen. The position opens up once each lifetime. The departing chief of neuropsychology has been there for decades and is retiring at 70-something years of age. 

The official job description arrived in my email the day after I put together my application package. My bad for sure as there are several key requirements that seem to be missing from my training and experience. Now I worry that the hiring committee will notice the lack of these credentials that are clearly spelled out in the job announcement. Perhaps some of the hiring committee will be amused and greet me cynically if I am chosen for a face to face. Fat chance now, right? 

Whenever I begin a blog post I make an effort to write with a higher frequency of support documentation for the ideas I introduce. So in this blog I want to describe what it has been like for me being scrutinized for employment after being at my present position for nearly 15 years. This post will be somewhat random and unfocused given my tenure here at Whittier and a strong underpinning of professional doubt.

In any position that puts one into a managerial role there will be naysayers. “they hired this guy?” Professional jealousy is a real workplace dynamic just like office romance. When I was promoted to sergeant when in law enforcement, people who encouraged me to apply became strangers when we came together at calls. I may have been the ranking officer on the call but I needed to be updated and briefed by my guys at the scene and rarely did anyone step forward. As a new manager, I did not know everything and on more than one occasion, I felt as though the troops wanted to see things go south. For me to fail. 

 I for one, strongly believe in professional mentoring and supervision. I did not get this in spite of going to sergeants school. At all levels new hires require support. I strongly believe in mentoring and usually have a graduate student or two here at the hospital. It is a lot of work but when a student shows they are ready to fly it can be very gratifying for me. It is a lot like coaching, without all the yelling and cold mornings at the ice rink. I would need a mentor in my new job if I am chosen. A braintrust with whom I can communicate daily and who will help me keep track of my mistakes and teach me the ropes. I am lucky to have wise, intelligent friends and family members who are there for me to whom I may turn as a sounding board. I do not know everything and expect to be taught the ins and outs of the new job by the rank and file within the parameters of the position. I do not need to be the loudest man in the room.

As luck might have it, I received a call back from the medical director’s assistant. The hiring committee has some “additional questions” they want answered. I am now very excited. Like my research interests, mentoring, leadership goals for the department, etc. I will work on these in the days ahead. It is only is fitting that I write about my vulnerable feeling at submitting my CV for the most venerable position in Boston. Updating one’s resume after greater than 10 years is a humbling experience for sure. There are so many experts in the field. Excitement waned as I read a condensed version of my career highlights. Suddenly, I realize just how professionally flawed I am. Lazy even. Yet there were physician colleagues who encouraged me to stick with it and spoke on my behalf to the primary physician on the hiring committee. 

The entire process went on for months. My colleague who encouraged me to apply said they had narrowed the field down to 3 candidates and just today one had been eliminated and it was not me. Suddenly, I was filled with both excitement and intrepid self-doubt. Could that be right? The position of chief was between me and one other. Soon after hearing that the pool was dropped to 2 applicants,  I learned that infact, I was number 3 and was no longer being considered. Still I am grateful for the opportunity to be third on the list at the finest psychiatric hospital in the country. Such are the highs and lows when a job that comes open once in a lifetime and a professional maelstrom erupts in the aftermath of the not-yet cool office chair.

 I have a job and when I retire, it will the first time in a lifetime that it will be open. For that I am very fortunate and grateful. 

“Long haul cognitive effects of Covid-19” in those who have “recovered”

There are now sufficient numbers of individuals who have had the coronavirus during the past 15 months who are presenting to their physicians with lingering symptoms of the disease. They are now known as long-haulers. People who have sometimes multiple complaints that suggest to researchers that they are a different group of patients. They tend to be younger, they generally have more complex medical histories including a variety to pulmonary conditions, and they are not the case you might expect to be most debilitated. This report is derived from the literature recent review and live zoom presentation on the Cognitive Impact on Long-haul survivors of the coronavirus held on May 20, 2021. It is available on the Whittier Health website. I want to thank Lauren Guenon, MS, SLP, CBIS for her help in this program and the data mining we are continuing.

Coronavirus molecule under magnification

It was first reported that overwhelming viral spread was thought to be primarily respiratory. The virus multiplies inside the body and is likely to cause mild symptoms that may be confused with a common cold or flu. This changes in many as the viral load evokes a cytokine autoimmune response in the body. As the virus takes, hold during the worsening pulmonary phase primarily respiratory symptoms such as persistent cough, shortness of breath, and low oxygen levels are observed. Too many survivors say the ignored this phase and just tried to rest at home. Often they were transported to hospital after being overwhelmed by the inflammation in their lungs and other organs. Hyperinflammatory phase, occurs when a hyperactivated immune system may cause injury to the heart, kidneys, and other organs as covid-19 devours healthy cells leading to death of cells in a process called apotosis.

Experience shows most long-haulers were expected to fall into the high risk category. like those with chronic COPD, but there is also a growing percentage of people who were otherwise healthy before they became infected and are not the older, sicker cases first described.

About 33% of COVID-19 patients who were never sick enough to require hospitalization continue to complain months later of symptoms like fatigue, loss of smell or taste and “brain fog,” that can interfere with functional tasks including the return to work.

University of Washington (UW)

It remains unclear if neurological complications are due to the direct viral infection of the nervous system, or they are a consequence of the immune reaction against the virus in patients who presented pre-existing deficits or had a certain detrimental immune response from their immunocompromised status when infected. 38 males, ages 22-74

The first studies of long haul survivors are being published. They are small studies reporting on the Italian first wave in 2020. The cases are hospitalized, non-intensive COVID units in Milan, Italy. These were not the patients who needed intubation or ventilatory support. Most had ARDS (mild, moderate, severe) Ferrucci, R et al. Subjectively, 31.6% reported overall cognitive decline 4-5 months after discharge when they were screened using a commonly administered cognitive test, then assessed using BRB-NT. Results for this group of moderately infected patients included: 42.1% processing speed deficits; 26.3% delayed verbal recall; 10.5% immediate verbal recall; 18.4% impaired visual long term memory, 15.8% visual short term memory; and 7.9% semantic verbal fluency deficits. Helms et al. reported on 58 patients who were evaluated in the ICU with over a third (33%) exhibiting dysexecutive syndrome, poorly deployed attention, and decreased capacity for organization

In another Italian study, 81% of patients had cognitive deficits including difficulty in areas of attention and executive functioning with pronounced weaknesses in divided and sustained attention (complex attention) set-shifting, speed of processing, and working memory. This was a group of 57 patients who were sent to acute rehabilitation after they were cleared of having active virus. All were debilitated and had a mean age of 64. 75 percent were male, 61 percent non-white and 56 percent were fully employed. In this group 88 % had suffered hypoxic respiratory failure with most being intubated for ventilatory support. 29% went on to get a tracheostomy tube inserted indicating a likely longer-term need for breathing support. 84 % need assistance with activities of daily living, has impaired mobility, and support for IADL’s. Neuropsychology services saw them an average 6.6 days after admission to the rehabilitation hospital. In general, the Whittier cases admitted for covid-recovery were referred to a neuropsychologist within 48 hours of admission. Ventilation-induced hypercapnia has been experimentally shown to lead to cognitive impairment due to acute inflammatory response advancing the cytokine storm and its multi-system impact.

Studies have described long-term risk and short-term risk to cognitive health from the coronavirus. Severe cognitive decline like dementia may be associated with co-occurring illness from anoxia, respiratory failure, blood clots and is associated with more severe disease and chronic long lasting symptoms. These are linked to prolonged risk of systemic inflammatory illness, increased risk of stroke and white matter disease within the brain and even reported cases of acute transverse myelitis (Budson,A, 2021). Budson reported on symptoms in 30-50 percent of people who experienced mild to moderate disease. Zhou et al. described a sample of 29 patients who were assessed 3 weeks after discharge home who were found to have dysfunction in the system of attention – most notably in sustained attention and reaction time. This may be the result of decreased mental endurance, slow processing and fatigue that are reported across several studies reported here. These patients were positively coorlated with C-reactive protein – a marker of the bodies inflammatory response when elevated.

Elevated level of CRP may be a valuable early marker in predicting the possibility of disease progression in non‐severe patients with COVID‐19, which can help health workers to identify those patients an early stage for early treatment.

Nurshad, A 2020

Rampage published in the table below in the American Journal of Speech Pathology in 2020. The long-haul covid-recovered are likened to patients described as having post-intensive care syndrome that occurs as a result of the changes in the system of cognition and emotional regulation. This is one of the best tables I have seen that illustrates the impact of the virus and the systems that are impacted. Rampage et al.

Delirium is another concern and fits in with what is called post-ICU syndrome (PICS), a collection of problems that can present—and linger—after a critical illness.  “The three domains we worry about are impairments in physical function, cognitive function, and mental health” .

Yale School of Medicine Carrie MacMillen June 2020 

The long term impact may be seen later on in life. Chronic systemic inflammation has been shown to promote cognitive decline and neurodegenerative disease makes it more likely that COVID-19 survivors will experience neurodegeneration in later years that has been known for a long time. Those with short term cognitive consequences may have had less viral load and for a shorter duration of time. Interestingly, those who were in covid-recovery units and on ventilators tended to report less cognitive symptoms suggesting there may have been some protective element to consistent ventilatory or simply timing and getting to the hospital before the hyperinflammatory (cytokine storm) phase of the viral process. A global increase in the prevalence of fatigue, brain fog, depression and other “sickness behavior”-like symptoms implicates a possible dysregulation in neuroimmune mechanisms even among those never infected by the virus .

Whittier Rehabilitation Hospital in Westborough, MA is looking at the data of 73 patients. This is very likely the first and largest subset of surviving long haul cases of the coronavirus. Our population is older 70.6 years, 66% white males versus approximately 64 years reported in the Italian studies reported here. The Italian samples were largely male as well. The average length of stay was 19.6 days. 21% had signs and symptoms of clinical depression or generalized anxiety co-occurring with their physical and cognitive symptoms. 14% had persistent delirium and encephalopathy.

Recovery from the long-haul symptoms reported in this paper will take weeks to months we predict. It has been recommended that aggressive multidisciplinary rehabilitation be initiated as soon as endurance permits. Intensity shoould include 4-5 times a week PT, OT, and speech language pathology. In many cases the comorbid depression and anxiety must be dealt with concurrent to the restorative physical and cognitive work. Some have likened the neurocognitive impact of covid-19 to that of a moderate traumatic brain injury in the breadth of its impact and tough return to a semblance of normalcy. Aggressive treatment is strongly recommended and should be commensurate with endurance and debility. There is evidence that the likelihood of full return to work is decreased after 6 months or more of recovery.


References

Ferrucci, R et al., (2021) Brain Sci. 11, 235.

Jaywant et al., (2021) Neuropsychopharmacology, 0:1-6

Budson, A. (2021) B.U.Medical School — https://www.health.harvard.edu/blog/author/abudson

Heneka et al. (2020) Alzheimer’s Research & Therapy. Long and Short-term Cognitive Impact of Coronavirus. 12:69 https://doi.org/10.1186/s13195-020-00640-3

Lawton, MP, Brody, EM. (1969). Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 9(3): 179-186.

Ramage, A. Potential for Cognitive Communication Impairment in COVID-19 Survivors:  A Call to Action for Speech Language Pathologists.  Nov. 2020, American Journal of Speech-Language Pathology.  Vol. 29. 1821-1832 

Sigurvinsdottir, R, Thorisdottir, I, Gylfason, HF. (2020). The Impact of Covid-19 on Mental Health: The role of Locus of Control and Internet Use. International Journal of Environmental Research and Public Health, 17:6985: doi:10.3390/ijerph17196985.

Nurshad, Ali, (2020) J Med Virol. Jun 9 : 10.1002/jmv.26097.

Ludovica Brusaferri, Zeynab Alshelh, Daniel Martins, Minhae Kim, Akila Weerasekera, Hope Housman, Erin J. Morrissey, Paulina C. Knight, Kelly A. Castro-Blanco, Daniel S. Albrecht, Chieh-En Tseng, Nicole R. Zürcher, Eva-Maria Ratai, Oluwaseun Akeju, Meena M. Makary, Ciprian Catana, Nathaniel D. Mercaldo, Nouchine Hadjikhani, Mattia Veronese, Federico Turkheimer, Bruce R. Rosen, Jacob M. Hooker, Marco L. Loggia (2022) The pandemic brain: Neuroinflammation in non-infected individuals during the COVID-19 pandemic, Brain, Behavior, and Immunity, Volume 102, Pages 89-97, ISSN 0889-1591, https://doi.org/10.1016/j.bbi.2022.02.018.


Law Enforcement and Mental Health: Insanity rules the day

Westborough, MA August 30, 2018 In the process of writing the Police Chief’s Guide to Mental Illness: Mental Health Emergencies, Leo Polizoti, Ph.D. my co-author and I quickly discovered that it is often not easy to identify people experiencing mental health crisis or emergency.  Many are not forthcoming with the specific underpinning of their particular disorder because of embarrassment and shame associated with mental disability. For many the stigma of being labelled “mentally ill” is more than they can bear. Nevertheless, “the Treatment Advocacy Center, a nonprofit that studies topics related to mental health, has calculated that the odds of being killed during a police encounter are 16 times as high for individuals with untreated serious mental illness as they are for people in the broader population” according to Nathaniel Morris, M.D. in an article espousing the benefits of having psychiatric physicians under contract to provide consultation for police encounters with the mentally ill.
A program in Albuquerque, NM does just this by having a full-time physician on the staff for both training and face-to-face consultation. This is a costly endeavor whereas the average psychiatrist earns nearly $ 200,000 annually. The thought is that as a medical doctor greater acumen in distinguishing organic syndromes like dementia from more common disorders such has depression or anxiety. I agree but other clinicians when properly trained may provide similar expertise at a more cost effective salary. Many co-responder programs have master’s level clinicians riding with law enforcement. Generally a physician is employed when you expect patients or such clientele to be prescribed medication and follow up.  My sense of the New Mexico program does not include medication management in its charge. Yet even physicians have difficulty differentiating the sane from the psychologically unwell.
In a famous study, Rosenhan suggests that the label associated with being schizophrenic causes the hospital staff to make misguided assumptions about the patients’ behavior through no fault of their own.  When someone is seen as mentally ill, everything they do may be interpreted as symptomatic of their disorder.
The psychological autopsy method entails reconstructing a biography of the deceased through psychological information gathered from personal documents; police, medical, and coroner records; and first-person accounts, either through depositions or interviews with family, friends, coworkers, school associates, and physicians. One of the major contributions of psychological autopsies “has been to introduce the psychosocial context into decisions about the cause of death since examination of postmortem remains tell only what lesions the patient died with, not what he died from.”
”Studies have shown that there are certain commonalities to suicide completers. Indeed, “they found that persons who commit suicide are likely to be unmarried, unemployed, living alone, and depressed”. Clark et al. found that suicide completers are twice as likely to be male, almost always qualify for a psychiatric diagnosis, and more often than not communicate intent. Sanborn et al found that the protoypical suicidal individual is not currently employed, is experiencing acute stress and frustration in areas apart from work, and has an alcohol problem. Moreover, such risk factors for suicide have been found to vary by age group. Adolescent suicide completers often have a history of physical and sexual abuse, parental psychiatric problems, and commit suicide in the context of an acute disciplinary crisis, elderly suicide completers often have a history of chronic or terminal disease. Persons who are addicted to alcohol or drugs and are having suicidal ideation are more likely to harm themselves. Some call the police officers who are set up to use lethal force when facing an intoxicated subject who is armed with a weapon.  When faced with lethal force, law enforcement is trained to use strategies to slow the scene and de-escalate whenever possible. Suicide by cop is a known phenomena. Family members frequently call the police when a family member arms himself with a firearm of knife expecting the police to simply disarm the subject. But in truth, the subjects actions are what guide police behavior not the other way around. Someone under the influence does not understand these principles and had they been unarmed and sober some might have been spared. No police officer ever wants this situation to become a reality.
REFERENCES
Essays, UK. (November 2013). On Being Sane In Insane Places. Retrieved from https://www.ukessays.com/essays/psychology/on-being-sane-in-insane-places-psychology-essay.php?vref=1 Taken July 26, 2018
Polizotti, L and Sefton, M (2018) The Police Chief’s Guide to Mental Illness and Mental Health Emergencies. Decision Press.

“Long haul cognitive effects of Covid-19” in those who have “recovered” Live zoom presentation by Whittier Rehabilitation Hospital – it was a lively event.

MICHAEL SEFTON

Thanks for those of you who signed on the last night’s webinar.  The Zoom presentation will be available at the Whittier Health website in the next couple weeks if interested. As we learned, even patients’ with mild infection can experience long lasting cognitive impact from the Covid-19 virus in the areas of memory, concentration, mental endurance, organization and verbal expression. There are mental health concerns as well that should not be overlooked.  Recovery from the virus can take weeks to months after the termination of treatment.  

The presentation on the impact of cognitive and behavioral functioning on ‘long haul’ cases is somewhat concerning given the 32 million Americans who have suffered with the virus. This is the second in a series produced by WRH and follows the November 2020 presentation on the psychological impact of the disease.  We will have a post here on the discussion from the webinar in the coming days.  The early studies have shown data from the population in Italy who have recovered from the virus in the first wave of the pandemic.

Frontline casualties

“Depression and anxiety in the face of global trauma — or for that matter, in the face of post-partum depression, divorce, crushing debt — are not major mental illness. They are natural responses to acute stress and crises. Therapeutic options should be offered without fear of career cost, and statistics, though poor dinner companions, have described the problem clearly. Every physician in every state should be guaranteed safety when they seek help. They should seek help so that — using their hard-won, often astonishing expertise — they can help the rest of us.” Elissa Ely, MD is a psychiatrist