First Impressions of Performing Bedside Cognitive Assessment of COVID‐19 Inpatients

Short abstract

See the Reply by Phillips et al.

To the Editor: Natalie Phillips and colleagues very helpfully outline some of the challenges encountered when performing cognitive screening via telemedicine.1 The authors focus in particular on the use of the Montreal Cognitive Assessment2 and the significant obstacles encountered during nonstandardized remote administration of the test. I outline here some of the challenges encountered when performing bedside cognitive assessment of coronavirus disease 2019 (COVID‐19) inpatients with acquired brain injury, degenerative conditions, or other neurologic diagnoses.

1. Wearing personal protective equipment (PPE) poses several logistical challenges for performing bedside cognitive assessment. For example, paper‐and‐pencil tasks cannot be taken into the ward for use during the assessment. For timed tasks, even where permissible to wear a wristwatch, these cannot be seen underneath the PPE. Furthermore, ward wall‐mounted clocks may not always be visible for time tasks.

2. Perceptual problems are accentuated by wearing PPE. Speaking through a mask to patients who might have processing or hearing impairment as part of acquired brain injury or other neurologic insult makes bedside cognitive assessment difficult to perform with assured reliability and validity. Conversely, wearing PPE is uncomfortable and hot, and it can make it difficult to observe your patient’s performance as well as you would like.

3. Factors related to COVID‐19 itself can influence the findings of bedside cognitive assessment. Patients with COVID‐19 often experience debilitating fatigue that may adversely affect their cognitive performance. Patients may only be able to tolerate short bedside cognitive screening. It can be difficult to disentangle what accounts for observed underperformance: COVID‐19–associated symptoms such as fatigue, brain injury/other neurologic factors, or both.

4. Psychological factors can affect the bedside cognitive assessment and its findings. COVID‐19 is a frightening new disease that has caused severe global disruption. When seeing ward‐based inpatients with COVID‐19, anxiety can influence the reliability and validity of their performance. Patients’ anxiety can be further accentuated by the challenges associated with wearing PPE that can hinder the clinician in creating a reassuring and calm environment within which to assess patients.

5. The consultation per patient takes more time. Changing into surgical scrubs, fitting and removal of PPE, and showering upon leaving the ward is time consuming. As a result, fewer patients can be assessed during each ward visit than would normally be the case. These COVID‐19 infection control measures also prevent note taking to serve as a memory aid of patients’ cognitive presentation because taking paper notes from a COVID‐19 ward for later dictation would pose a contamination risk, reducing the efficiency and increasing the time required for performing cognitive screening of ward patients.

COVID‐19 poses many challenges to the care of patients with suspected or confirmed cognitive impairment or neurologic and neuropsychological problems. During the COVID‐19 crisis, clinicians will continue to receive referrals requesting cognitive assessment of these patients, to help inform their ongoing care. However, some adaptations to practice are most likely needed. Performing cognitive assessment of inpatients under the restrictive conditions imposed by COVID‐19 requires a flexible approach without the normal assessment tools at our disposal. Accordingly, an awareness of issues pertaining to reliability, validity, and interpretation of results under these circumstances is crucial as well. Allowing extra time for consultations and managing clinician fatigue is important. Clinicians should assess for noncognitive factors, in particular anxiety, as well as fatigue. Despite these challenges, patients should not be deprived of clinical assessments that could have important implications for their post–COVID‐19 care and rehabilitation.